Cezar Staniloae

Enterococcus Faecalis Infective Endocarditis Following Percutaneous Edge-to-Edge Mitral Valve Repair

An 85-year-old woman presented with severe degenerative native mitral regurgitation (MR) in the setting of preserved left ventricular ejection fraction (LVEF) of 65%. Transesophageal echocardiography (TEE) demonstrated a flail P2 scallop and she subsequently underwent percutaneous mitral valve repair with MitraClip®. Four months later, she presented with fatigue, chills, and dyspnea. Blood cultures grew Enterococcus faecalis sensitive to ampicillin. Repeat TEE demonstrated a 1.2 cm × 0.6 cm mobile echodensity associated with the left atrial aspect of the MitraClip® consistent with vegetation with recurrence of severe MR. Given the patient’s advanced age, comorbidities, and poor functional class, surgical mitral valve replacement (MVR) was not deemed appropriate. The patient exhibited rapid clinical decline and expired shortly thereafter. A second case involves a 57-year-old man with severe degenerative native valve MR who underwent percutaneous mitral valve repair with placement of two MitraClips®. Two months later, he presented with acute decompensated heart failure. Blood cultures grew Enteroccus faecalis and a TEE demonstrated a new mobile echodensity on the atrial aspect of the P3 scallop and involving the medial MitraClip® consistent with vegetation. There was new, severe posteriorly directed MR with two jets. The patient was treated with 6 weeks of IV antibiotics. Several months later he had stable NYHA Class II–III symptoms with a repeat transthoracic echocardiogram showing improvement of MR and no evidence of vegetation. The first case of infective endocarditis with MitraClip® was described in 2011. Only a few other cases of this complication have been published since. To our knowledge, these two cases are the first documented cases of Enterococcus faecalis mitral valve endocarditis associated with MitraClip®.

In-vivo measurement of coronary Angiotension-Converting Enzyme (ACE) activity in humans

The relationship between atherosclerosis and ACE activity is unclear.We tried to establish whether the endothelium bound coronary ACE activity correlates with coronary atherosclerotic burden. Methods. A single bolus indicator-dilution experiment was performed in 10 patients. Trace amounts of the specific ACE substrate 3H-benzoyI-Phe-Ala-Pro (3H-BPAP) and of the myocardial interstitial space reference 14C-sucrose were injected in the left main coronary artery. Serial samples were obtained from the coronary sinus. Plasma concentrations of residual substrate and end-product (3H-BP) were measured. Mean transit time of each tracer and myocardial plasma flow (~) were determined. The curves were modelled to compute the rate constant for 3H-BPAP hydrolysis by ACE (Kh). Coronary angiograms were scored for atherosclerotic burden according to 2 previously described techniques to obtain the plaque area index (PAl)and Sullivans extent score (SES). Spearman correlation test was used to calculate p values. Results. The atherosclerotic burden extent scores correlated well with each other (r= 0.82; p=0.002), There was a weak correlation between K h and measures of atherosclerotic burden (r =0.4; p=0.22). Conclusion. The indicator-dilution technique is a safe tool to quantify endothelium bound coronary ACE activity. The weak correlation between endothelium bound coronary ACE activity and extent scores suggests that tissue ACE may play a more important pathophysiologic role in the disease process, March 6, 2002 ABSTRACTS Hypertension, Vascular Disease, and Prevention 267A