We report a case of Gemella morbillorum mitral bioprosthetic valve endocarditis with perivalvular extension in a 44-year-old human immunodeficiency virus-positive man who is an active intravenous drug user together with review of all published cases. This is only the second reported case of Gemella morbillorum endocarditis in a patient with a prosthetic valve. CASE REPORTA 44-year-old human immunodeficiency virus-positive man with a history of active intravenous drug use and a mitral valve replacement only 9 months earlier for native-valve endocarditis due to Staphylococcus aureus was admitted complaining of pleuritic chest pain, shortness of breath, fever, and chills.Physical examination revealed a temperature of 99.8°F, blood pressure of 114/70 mm Hg, a regular heat rate at 98 beats per min, and a grade III/VI holosystolic murmur radiating to the axilla. No clinical signs of congestive heart failure (such as pulmonary rales or peripheral edema) were noted.An electrocardiogram was notable for a first-degree atrioventricular block (an increased PR interval of 0.22 s) and nonspecific T wave changes. Laboratory investigations were significant for a normocytic anemia with a hemoglobin level of 10.9 g/dl and an elevated erythrocyte sedimentation rate of 108 mm per h. However, neither the total white blood cell count nor the percentage of banded neutrophils was elevated (3.72 ϫ 10 9 /liter and 4% bands, respectively). Three sets of blood cultures were obtained prior to initiating antibiotic therapy. Blood samples were incubated in a continuous-monitoring culture system (Bac T/Alert; Becton Dickinson, Organon Teknika, Durham, N.C.) at 37°C. After 24 h of incubation, growth in the anaerobic bottle was noted. The samples were then subcultured at 37°C on MacConkey's agar, sheep blood agar, anaerobic CDC blood agar, and chocolate agar incubated in CO 2 .After 24 h of subculture incubation, an alpha-hemolytic organism grew on all plates except the MacConkey agar. The organism was further characterized as being a gram-positive coccus that was both catalase and bile solubility negative.These initial findings suggested that the organism was Streptococcus viridans. However, on further evaluation with an API 20 streptococcus identification system (Bio Merieux, Vitek Inc., Hazelwood, Mo.), the organism was identified as Gemella morbillorum with 98% confidence.Antimicrobial susceptibility by disk diffusion method showed the organism to be sensitive to ceftriaxone, clindamycin, levofloxacin, tetracycline, and vancomycin, while the Etest showed sensitivity to penicillin G.A transthoracic echocardiogram revealed severe regurgitation through incompetent leaflets of the bioprosthetic mitral valve. On spectral Doppler recording of the prosthetic inflow, a severely elevated mean diastolic gradient of 22 mm Hg at a sinus heart rate of 75 beats per min was noted. Since there were no echocardiographic signs of prosthetic stenosis (the pressure half-time was only 77 ms), this gradient was indicative of severely elevated left atrial pressure...

OCT-guided atherectomy for femoropopliteal disease is safe and effective. Additionally, the precision afforded by OCT guidance leads to greater removal of plaque during atherectomy while sparing the adventitia.

It is well recognized that patients with severe left ventricular (LV) systolic dysfunction develop pulmonary venous hypertension or postcapillary pulmonary hypertension, which leads to an increase in pulmonary vascular resistance (PVR) and right ventricular (RV) systolic failure. It is often underrecognized, however, that patients with heart failure with preserved LV ejection fraction and diastolic dysfunction may also develop postcapillary pulmonary hypertension with elevated PVR leading to RV systolic failure. This form of biventricular failure is a result of diastolic failure on the left in patients with preserved LV ejection fraction and systolic failure on the right. At this time, there are no randomized trials or guidelines addressing the management of patients with diastolic heart failure with and without resultant RV failure. The authors review the pathophysiology, clinical presentation, and suggested treatment of this underrecognized clinical entity.

In many patients, the treatment of heart failure (HF) cannot be optimized because of pre‐existing or treatment‐induced hypotension. Midodrine, a peripheral α1‐adrenergic agonist may allow for up‐titration of neurohormonal antagonist therapy leading to improved outcomes. Ten consecutive patients with HF due to systolic dysfunction and symptomatic hypotension interfering with optimal medical therapy were started on midodrine. After a 6‐month follow‐up, a higher percentage of patients were on optimal HF therapy (angiotensin‐converting enzyme inhibitor/angiotensin receptor blocker mg % of optimal dose 20% vs 57.5%; P<.001) (β‐blockers mg % optimal dose 37.5% vs 75%; P<.001) (spironolactone/eplerenone mg % 43.7% vs 95%; P<.001). This led to an improvement in left ventricular ejection fraction (baseline 24±9.4 vs 32.2±9.9; P<.001) and clinical outcomes, with a significant reduction in total hospital admissions (32 vs 12; P=.02) and total hospital days (150 vs 58; P=.02).

We report a case of a 52-year-old man with multiple myeloma and rapidly progressive heart failure who died unexpectedly from a probable arrhythmia. Postmortem examination revealed infiltrative amyloid cardiomyopathy, a rare cause of predominantly diastolic myocardial disease. Cardiac amyloidosis should be considered in any patient presenting with congestive heart failure, preserved systolic function, and a discrepancy between a low QRS voltage on electrocardiography and an apparent left ventricular hypertrophy on sonogram. The pattern of left ventricular diastolic dysfunction changes during the course of amyloidosis and the classically described restrictive physiology occurs only in advanced stages of the disease.