Patient: Male, 39-year-old Final Diagnosis: Degenerated bioprosthetic mitral valve Symptoms: Chest pain • cough • dyspnea • orthopnea • paroxysmal nocturnal dyspnea Medication: — Clinical Procedure: Transcatheter mitral valve replacement Specialty: Cardiology Objective: Unusual clinical course Background: A 39-year-old man with a complex valvular history of recurrent methicillin-resistant Staphylococcus aureus endocarditis with 2 surgical mitral valve replacements (in 2016 and 2017) followed by transcatheter mitral valve replacement (in 2019) presented with orthopnea, paroxysmal nocturnal dyspnea, chest pain, cough, and progressively worsening dyspnea on exertion. Case Report: Extensive workup was performed, including transesophageal echocardiogram, which revealed a malfunctioning, severely stenotic bioprosthetic valve. Left and right heart catheterization revealed mild non-obstructive coronary artery disease and severe pulmonary hypertension. Given the patient’s complex medical history, he was deemed to be at an elevated risk for repeat sternotomy and repeat valve replacement surgery. Therefore, he underwent a percutaneous transcatheter mitral valve replacement with a 26-mm SAPIEN 3 Edwards valve placed within the previous 29-mm SAPIEN valve. Post-procedural imaging revealed a well-placed valve with an improved mitral valve gradient. Conclusions: This is one of the few rare cases of mitral valve-in-valve via a transcatheter mitral valve replacement approach with successful deployment of a SAPIEN 3 tissue heart valve. The patient experienced significant reversal of heart failure symptoms and improved exertional tolerance following deployment of the valve and was eventually discharged home in a stable condition.

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Introduction: Cardiac necrotizing soft tissue infections (NSTI) have been scarcely reported in the literature. We present a rare case of a disseminated NSTI with myocardial involvement secondary to embolic phenomena from emphysematous infective endocarditis (IE). Case presentation: 73-year-old female on dialysis with atrial fibrillation and diabetes mellitus was transferred for multifocal strokes evidenced on magnetic resonance imaging. Presented with leukocytosis, lactic acidosis, acute liver failure, and right upper extremity (RUE) NSTI. She was started on antibiotics and vasopressors and taken emergently to the operating room for RUE amputation. Following surgery, an electrocardiogram revealed anterior STEMI. Bedside transthoracic echocardiogram noted a severely reduced ejection fraction and a mitral valve vegetation. Computed tomography of head and chest revealed pneumomyocardium, portal venous gas, and pneumocephalus. Blood cultures revealed growth of Clostridium perfringens. With severe multi-organ failure and a poor prognosis, comfort care was elected, and the patient expired. Figures: A: RUQ subcutaneous gas. B: Chest wall gas. C: pneumocephalus. D: pneumomyocardium. E: MV vegetation. Discussion: Septic embolization is a devastating sequela of IE. Vegetations > 1cm have increased embolic potential and all-cause mortality. The most common site of embolization is the central nervous system; however, coronary embolization can also occur. Clostridial endocarditis is rare, despite being documented as the first cause of anaerobic IE. Mortality rate of clostridial NSTI and shock exceeds 50%. Source control and rapid identification of infection are paramount for treatment success. A multidisciplinary approach should be employed when treating Clostridial infections, specifically endocarditis. Our case highlights the need for prompt recognition of IE and the interplay of multimodal imaging in the diagnosis of disseminated infection.