Vargha, Jalal

Background: Current guidelines recommend proceeding with cardioversion, without the explicit need for preprocedural transesophageal echocardiography (TEE), in patients compliant with oral anticoagulation for at least 3 weeks. The relevance of these guidelines remains unclear in those undergoing repeat cardioversion. Case summary: A 66-year-old male with a history of atrial fibrillation (AF) and a left atrial appendage occlusion (LAAO) device, compliant with apixaban, presented with dyspnea and lightheadedness. He was cardioverted into sinus rhythm, 10 days before symptom onset, with TEE unremarkable at the time. An ECG revealed that the patient converted back into AF and a repeat cardioversion was scheduled. At the patient’s request, a TEE was obtained, revealing a new 2 cm×1 cm thrombus in the left atrium above the WATCHMAN device. Cardioversion was canceled and the patient was hospitalized for AF management. Discussion: Cardioverted patients are at risk for thrombus formation due to atrial stunning, a transitory dysfunction of the atrial appendage and atrium, which occurs immediately after cardioversion and can persist for several weeks. The likelihood of a thrombus is further propagated by individual risk factors for stroke. Conclusion: Anticoagulation does not eliminate the risk of thrombus formation in those with increased risk factors for stroke. Further studies are warranted to assess the need for routine TEE, after cardioversion, in those with stroke risk factors on anticoagulation or who have LAAO.

Introduction: Patients with sickle cell disease are at risk for many types of cardiac complications. We present a case of endocarditis of the superior vena cava (SVC) in a 22-year-old male with sickle cell disease. Case study: A 22 year old male with sickle cell disease presented to the hospital with 3 days of fever, night sweats, generalized body pains, vomiting and poor oral intake. 6 weeks ago, he had been admitted to an outside hospital for Methicillin related Staphylococcus aureus (MRSA) bacteremia. At that time an implanted venous access port in the patient’s chest was removed and 4 weeks of intravenous(iv) vancomycin were administered. He was admitted to the hospital for sepsis. Blood cultures were drawn which were positive for MRSA. A transesophageal echocardiogram revealed a large mobile vegetation in the SVC ( Fig. 1) The proximal end of the vegetation extended beyond the echocardiographic field of view, so a CT scan of the chest with contrast was performed (Fig. 2) This showed intraluminal filling defects in the distal SVC along with pulmonary emboli in the lower lobes of the lungs bilaterally. His antibiotics were changed to iv daptomycin and ceftaroline but he remained persistently bacteremic for 14 days. Therefore, removal of the SVC vegetation/thrombus was performed using AngioVac venous drainage cannula system. This was followed by resolution of bacteremia, and he was discharged from the hospital 9 days later. Conclusion: Echocardiographic evaluation of endocarditis should involve a comprehensive evaluation of all cardiac structures and not be limited to valves only. AngioVac venous drainage cannula system can be used to remove infected vegetations/thrombus.