Iatrogenic Right Sided Infective Endocarditis in Children with CHD

Background: Right sided endocarditis (IE) occurs predominantly in intravenous drug abusers, and occasionally acquired in hospital as a result of contaminated intravascular devices. The iatrogenic IE of tricuspid valve in children treated with intravenous (IV) injections for various unrelated conditions is not reported in literature. Objective: Aim is to report clinical outcome, microbiological and echocardiographic presentation of iatrogenic right sided IE in 4 children. Materials and methods: In a span of 3 months four children, age ranging from 1 month to 5 years, three females and one male, who presented with prolonged history of fever formed the material for this study. Two cases had ventricular septal defect (VSD), one had a small atrial septal defect (ASD) and one patient had tetralogy of Fallot (TOF). The blood culture grew coagulase negative staphylococcus in two patients and gram negative bacilli in the one month infant. The diagnosis of tricuspid valve endocarditis was established by transthoracic echocardiography (TTE) in all the four patients. In addition to vegetation on tricuspid valve, the vegetation was also detected in inferior vena cava (IVC) in one case and in another case a large vegetation was seen closing the VSD. Discussion: Right sided endocarditis accounts for only 5 - 10% of cases of IE. It has been estimated that up to 76% of cases of endocarditis among IV drug abusers involve the right heart, compared with only 9% in non-addict patients. The bacterial endocarditis is extremely rare in cases of ASD and TOF. This series of four cases is notable for the iatrogenic IE of tricuspid valve in children treated in the reputed hospitals with IV injections and IV fluids for various unrelated non cardiac conditions. The infection in this series occurred upon previously normal tricuspid valve. Three patients died (75%) and only one survived. Conclusions: Right sided endocarditis can occur in CHD patients when proper aseptic precautions are not taken while treating with IV injections. The blood culture and TTE play an important role in diagnosis and management of right sided IE

Aorto-ventricular tunnel

Aorto-ventricular tunnel is a congenital, extracardiac channel which connects the ascending aorta above the sinutubular junction to the cavity of the left, or (less commonly) right ventricle. The exact incidence is unknown, estimates ranging from 0.5% of fetal cardiac malformations to less than 0.1% of congenitally malformed hearts in clinico-pathological series. Approximately 130 cases have been reported in the literature, about twice as many cases in males as in females. Associated defects, usually involving the proximal coronary arteries, or the aortic or pulmonary valves, are present in nearly half the cases. Occasional patients present with an asymptomatic heart murmur and cardiac enlargement, but most suffer heart failure in the first year of life. The etiology of aorto-ventricular tunnel is uncertain. It appears to result from a combination of maldevelopment of the cushions which give rise to the pulmonary and aortic roots, and abnormal separation of these structures. Echocardiography is the diagnostic investigation of choice. Antenatal diagnosis by fetal echocardiography is reliable after 18 weeks gestation. Aorto-ventricular tunnel must be distinguished from other lesions which cause rapid run-off of blood from the aorta and produce cardiac failure. Optimal management of symptomatic aorto-ventricular tunnel consists of diagnosis by echocardiography, complimented with cardiac catheterization as needed to elucidate coronary arterial origins or associated defects, and prompt surgical repair. Observation of the exceedingly rare, asymptomatic patient with a small tunnel may be justified by occasional spontaneous closure. All patients require life-long follow-up for recurrence of the tunnel, aortic valve incompetence, left ventricular function, and aneurysmal enlargement of the ascending aorta

Iatrogenic Right Sided Infective Endocarditis in Children with CHD

Background: Right sided endocarditis (IE) occurs predominantly in intravenous drug abusers, and occasionally acquired in hospital as a result of contaminated intravascular devices. The iatrogenic IE of tricuspid valve in children treated with intravenous (IV) injections for various unrelated conditions is not reported in literature. Objective: Aim is to report clinical outcome, microbiological and echocardiographic presentation of iatrogenic right sided IE in 4 children. Materials and methods: In a span of 3 months four children, age ranging from 1 month to 5 years, three females and one male, who presented with prolonged history of fever formed the material for this study. Two cases had ventricular septal defect (VSD), one had a small atrial septal defect (ASD) and one patient had tetralogy of Fallot (TOF). The blood culture grew coagulase negative staphylococcus in two patients and gram negative bacilli in the one month infant. The diagnosis of tricuspid valve endocarditis was established by transthoracic echocardiography (TTE) in all the four patients. In addition to vegetation on tricuspid valve, the vegetation was also detected in inferior vena cava (IVC) in one case and in another case a large vegetation was seen closing the VSD. Discussion: Right sided endocarditis accounts for only 5 - 10% of cases of IE. It has been estimated that up to 76% of cases of endocarditis among IV drug abusers involve the right heart, compared with only 9% in non-addict patients. The bacterial endocarditis is extremely rare in cases of ASD and TOF. This series of four cases is notable for the iatrogenic IE of tricuspid valve in children treated in the reputed hospitals with IV injections and IV fluids for various unrelated non cardiac conditions. The infection in this series occurred upon previously normal tricuspid valve. Three patients died (75%) and only one survived. Conclusions: Right sided endocarditis can occur in CHD patients when proper aseptic precautions are not taken while treating with IV injections. The blood culture and TTE play an important role in diagnosis and management of right sided IE

Polyethylene glycols interact with membrane glycerophospholipids: is this part of their mechanism for hypothermic graft protection?

Polyethylene glycol (PEG), a high-molecular-weight colloid present in new organ preservation solutions, protects against cold ischemia injuries leading to better graft function of transplanted organs. This protective effect cannot be totally explained by immuno-camouflaging property or signaling-pathway modifications. Therefore, we sought for an alternative mechanism dependent on membrane fluidity. Using the Langmuir–Pockles technique, we show here that PEGs interacted with lipid monolayers of defined composition or constituted by a renal cell lipid extract. High-molecular-weight PEGs stabilized the lipid monolayer at low surface pressure. Paradoxically, at high surface pressure, PEGs destabilized the monolayers. Hypothermia reduced the destabilization of saturated monolayer whereas unsaturated monolayer remained unaffected. Modification of ionic strength and pH induced a stronger stabilizing effect of PEG 35,000 Da which could explain its reported higher effectiveness on cold-induced injuries during organ transplantation. This study sheds a new light on PEG protective effects during organ preservation different from all classical hypotheses