Introduction: Transcatheter aortic valve implantation is a routine clinical method for patients with severe aortic stenosis at high surgical risk, such as previous cardiac surgery. The presence of mechanical mitral prosthesis might complicate trans-catheter aortic valve implantation because of possible interference between both prostheses. Some clinical reports have already demonstrated the feasibility of trans-catheter aortic valve implantation in such patients.

Resting and exercise right heart catheterisation is the gold standard method to diagnose and differentiate types of pulmonary hypertension (PH). As it carries technical challenges, the question arises if non-invasive exercise stress echocardiography may be used as an alternative. Exercise echocardiography can unmask exercise PH, detect the early stages of left ventricular diastolic dysfunction, and, therefore, differentiate between pre- and post-capillary PH. Regardless of the underlying aetiology, a developed PH is associated with increased mortality. Parameters of overt right ventricle (RV) dysfunction, including RV dilation, reduced RV ejection fraction, and elevated right-sided filling pressures, are detectable with resting echocardiography and are associated with worse outcome. However, these measures all fail to identify occult RV dysfunction. Echocardiographic measures of RV contractile reserve during exercise echocardiography are very promising and provide incremental prognostic information on clinical outcome. In this paper, we review pulmonary haemodynamic response to exercise, briefly describe the modalities for assessing pulmonary haemodynamics, and discuss in depth the contemporary key clinical application of exercise stress echocardiography in patients with PH.

Background: Gamma-hydroxybutyrate (GHB) is an illicit drug causing unconsciousness and respiratory depression. The aim of this study was to evaluate the clinical presentation and treatment in patients admitted to the University Medical Centre Ljubljana (UMCL).Methods: In this study we included all retrospectively reviewed cases of GHB-poisoning admitted to the UMCL between 2000 and 2014. We collected all the data regarding the overdose circumstances, clinical presentation, treatment and toxicological analysis of blood and urine.Results: In the previous 15 years a total of 74 patients were admitted to the UMCL due to GHB-poisoning. The first case of GHB-poisoning was observed in 2002 and the numbers have largely increased since 2012. 86% of all the patients ingested the drug intentionally, 82% were male and the median age of admitted patients was 27 years. We recorded 6 mass GHB-poisonings in which 2-4 patients were admitted simultaneously. The most common presenting symptom of GHB-poisoning was diminished level of consciousness (95%), with 53% being unresponsive to pain. Vomiting (30%), bradycardia (28%), hypotension (26%), hypoventilation with respiratory insufficiency (19%) and agittation upon awakening (31%) were common as well. Concomitant alcohol and illicit drug use was recorded in 61% of cases. 80% of all the patients were treated symptomatically, 14% were mechanically ventilated.Conclusions: The incidence of GHB-poisoning has increased in recent years. GHB-poisoned patients are predominantly male, often admitted in groups, who ingest the drug intentionally at parties during weekends. The most common presenting symptom of GHB-poisoning is unconsciousness. Treatment is symptomatic.

Background Infective endocarditis can present without evident vegetation, diagnosis is challenging and prognosis very poor. We present an illustrative case where natural evolution of the mitral valve destruction with no evident vegetations was followed with frequent consecutive transthoracic (TTE) and transesophageal echocardiography (TOE). Case presentation 71-year old male with known dilated cardiomyopathy presented with dyspnoea, ankle swelling and severe kidney failure with hyperkalemia. During short hospitalization he was recompensated with haemodialysis, parenteral diuretics and inotropes. TTE showed dilated left ventricle with severe systolic dysfunction and no evidence of valvular disease. Few days after discharge he was readmitted with malaise and febrile state with no obvious site of infection. Blood cultures were positive for Staphylococcus aureus and antibiotic therapy was initiated immediately. Weekly TTEs and TOEs were performed (Figure 1, column A-D): Week 1: TTE was performed due to congestive heart failure. There was no suspicion on disease and TTE showed no obvious mitral valve pathology. Week 3: Second TTE showed only light thickening of posterior mitral leaflet with mild mitral regurgitation. Week 4: Follow-up TOE was performed showing posterior leaflet discontinuity with small eccentric regurgitation jet and no vegetation. Week 6: Symptoms of congestive heart failure persisted despite antibiotic treatment. A progressive destruction of posterior leaflet with evident perforation of P1 scallop and consequent severe mitral regurgitation. Patient was referred for urgent mitral valve replacement. Conclusions Staphylococcus aureus is a destructive pathogen and can cause severe destruction of native valve even without obvious vegetations. This case presents echocardiographic features of natural course of infective endocarditis on mitral valve. Despite antibiotic therapy progressive valve destruction is possible. Abstract P627 Figure.