12/2/16 Intern Morning Report – Aortic Coarctation, Endocarditis

CC: 2 weeks of shortness of breath

ID: 70 yo male with hyperlipidemia presents with progressively worsening shortness of breath, decreased exercise tolerance, and new 2 pillow orthopnea for the past 2 weeks.  He notes unintentional weight loss of ~18 pounds over the past 2 months, a near syncopal event 3 days ago, and lower back pain, worse at night, that radiates down both legs.  On exam, he was noted to have a 2/6 systolic murmur, a positive straight leg test on the right, and 1+ pitting edema to bilateral knees.  TTE demonstrated vegetations, consistent with endocarditis.  CXR demonstrated a slightly enlarged cardiomediastinal silhouette, which along with his history, prompted a CT Angiogram, showing coarctation of the thoracic aorta with 75% stenosis.

coarctation
CT Angio: There is coarctation of the thoracic aorta with 75% stenosis just distal to the ostium of the left subclavian artery origin and mild post-stenotic dilation of the descending thoracic aorta.
endocarditis
TEE: Small vegetations (less than 1 cm in diameter) noted on the right and non-coronary cusps.

Surgical Intervention in Native Valve Infective Endocarditis


Pearls from morning report:

  • In patients with a cardiac device, prosthetic valve, or prior valvular abnormality, it is reasonable to proceed directly to TEE and forgo a TTE to evaluate for endocarditis.
  • In patients with a high suspicion for endocarditis, but with a negative TEE, repeat the TEE in approximately 1 week.

Random trivia:

Dr. Inge Edler (1911-2001), a Swedish internist known as the Father of Echocardiography, was inspired by the use of RADAR in World War II to work with physicist Carl Hellmuth Hertz to develop the first “ultrasound cardiography.”


Want to read more?

Infective Endocarditis (New England Journal of Medicine)


References: 

Prendergast BD, Tornos P. Surgery for infective endocarditis: who and when? Circulation. 2010;121:1141-1152.

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