Acquired Ventricular Septal Defect in Panton-Valentine Leukocidin-Positive Staphylococcus aureus Infective Endocarditis

Infective endocarditis (IE) is life-threatening and can lead to complications if left untreated. A 56-year-old gentleman presented with acute delirium, fever and rigor. Panton-Valentine leukocidin (PVL)-positive Staphylococcus aureus (S. aureus) was isolated in the blood culture and the PR interval was prolonged on the electrocardiogram (ECG). However, the transthoracic echocardiogram (TTE) and transoesophageal echocardiogram (TOE) at presentation were unremarkable with no evidence of intracardiac vegetations. Despite expedient intravenous antibiotics, an acquired ventricular septal defect (VSD) developed, which required urgent cardiothoracic surgical repair. It is imperative to consider early surgical interventions and the use of anti-toxin antibiotics in PVL-positive S. aureus IE.

An unusual case of persisting hypoxia in a patient with a thrombolysed pulmonary embolism

Exertional breathlessness and hypoxia are common presenting complaints in acute medicine. We describe a case where the patient continued to have persistent hypoxia even after the primary cause (pulmonary embolism) was diagnosed and treated. The hypoxia persisted as an enigma, its cause remaining elusive till diagnosed. Standard first-line investigations would not have reached the underlying diagnosis in this case and, as such, it demonstrates the keen clinical sense and complex investigative strategy required to solve the puzzle.

An unusual cause of hypoxia: getting to the heart of the matter

A 63 year old female presented to hospital with progressive exertional dyspnoea over a 6 month period. In the year preceding her admission, she reported an intercurrent history of abdominal pain, diarrhoea and weight loss. She was found to be hypoxic, the cause for which was initially unclear. A ventilation-perfusion scan identified a right-to-left shunt. Transoesophageal echocardiography (TOE) demonstrated a significant right-to-left intracardiac shunt through a patent foramen ovale (PFO); additionally severe tricuspid regurgitation was noted through a highly abnormal tricuspid valve. The findings were consistent with carcinoid heart disease with a haemodynamically significant shunt, resulting in profound systemic hypoxia. 24 hour urinary 5-Hydroxyindoleacetic acid (5-HIAA) and imaging were consistent with a terminal ileal primary carcinoid cancer with hepatic metastasis. Liver biopsy confirmed a tissue diagnosis. The patient was commenced on medical therapy for carcinoid syndrome. She subsequently passed away while undergoing anaesthetic induction for valvular surgery to treat her carcinoid heart disease and PFO.

Clinical events and echocardiographic lesion progression rate in subjects with mild or moderate aortic regurgitation

Background: The rate of progression of aortic regurgitation (AR) is not well described. Current guidelines state that asymptomatic patients with mild AR should be followed up every 3–5 years and 1–2 yearly for moderate AR. This study describes the lesion and clinical based progression of mild and moderate AR in a population of patients undergoing systematic follow-up. Methods and results: 341 patients with either mild or moderate AR were included. The rates of clinical events (death, aortic valve replacement and cardiac hospitalization) and progression of AR are reported. 341 patients were included; mean age was 71.1 years (IQR 66–80 years) and the median follow-up period was 4.6 (IQR 2–6.7) years. 292 patients did not have any events during follow-up. 3 patients required aortic valve replacement (2 of these due to severe aortic stenosis and 1 due to severe mitral regurgitation and co-existent moderate AR). 44 patients required cardiac hospitalization. 9 patients died during follow-up and 35 patients (10%) showed a progression of AR during follow-up with an average time of 4.0 ± 2.6 years. 8 patients (2.3% of the total) progressed to severe AR. Patients with mixed valvular pathology showed a greater increase in AR progression (27 (15%) vs 8 (5%); P = 0.004). Conclusions: Over medium term systematic follow-up progression and clinical events in patients with AR is rare, regardless of etiology. Patients who suffered from AR as an isolated valve pathology were less likely to show AR progression over time.