We found increased systolic coronary flow in transthoracic pulsed wave (PW) Doppler in a 42-year-old patient with anomalous origin of left main coronary artery from the pulmonary artery. This is a characteristic echocardiographic finding in this anomaly in the presence of collateral circulation and coronary L-R shunt. In comparison with so far used echocardiographic criteria this parameter when present allows quick recognition of anomalous origin of left coronary artery from the pulmonary artery, and its differentiation from other potentially lethal coronary anomalies.

Introduction: Approximately three-fourths of patients with infective endocarditis have a preexisting structural cardiac abnormality at the time of the endocarditis development. Congenital heart lesions predisposing to infective endocarditis include aortic stenosis, bicuspid aortic valve, pulmonary stenosis, ventricular septal defect, patent ductus arteriosus, coarctation of the aorta, and tetralogy of Fallot. Complications of the infective endocarditis include cardiac, neurologic, renal, and musculoskeletal complications, as well as complications related to systemic infection. Cardiac complications are most common and they include: heart failure, perivalvular abscess, pericarditis, intracardiac fistula with myocardial perforation or aortic dissection. Management of patients with infective endocarditis includes antibiotic therapy as well as surgical treatment whenever it is indicated. 1-3Case report: We present a case report of a case report of a 29-year-old patient with congenital bicuspid aortic valve. Prior to the development of endocarditis the patient underwent a dental procedure without antibiotic prophylaxis. After couple of days he was hospitalized due to clinically signs of sepsis and infective endocarditis was reveled on echocardiography. Patient was treated with antibiotics but due to uncontrolled sepsis and severe aortic stenosis in a bicuspid aortic valve, signs of heart failure developed and patient underwent urgent cardiac surgery where the reconstruction of aortic annulus with bovine pericardium and mechanical aortic valve replacement was done. After surgery despite appropriate antibiotic therapy patient had continuous fever and clinical and laboratory signs of sepsis, so we suspected that abscess was formed. Due to that we performed 3D transesophageal echocardiography which revealed infective endocarditis vegetations on mechanical aortic valve, (Figure 1) paravalvular abscess, ventricular septal defect with significant left to right shunt and instability of mechanical valve, by itself, due to big abscess hole. (Figure 2, Figure 3). After that second cardiac surgery was performed where replacement of mechanical aortic valve with homograft was done, together with surgical repair of ventricular septal defect. After surgery transesophageal echocardiography showed normal function of replaced aortic valve, with mild regurgitation, no signs of infective endocarditis vegetations and without ventricular septal defect.Conclusion: Perivalvular abscess should be suspected in the setting of fever despite appropriate antimicrobial therapy. Transesophageal echocardiography is more sensitive for detection of myocardial abscess than transthoracic echocardiography.

Mucinous cystadenoma is a rare benign neoplasm and is usually discovered incidentally. Pleuritis and pericarditis, inflammation of the pleura and pericardium, may represent manifestations of autoimmune disorders especially in female subjects. We report a patient with polyserositis that was resolved after removal of the mucinous cystadenoma. To the best of our knowledge, this is a first report describing pleuritis and pericarditis as an initial presentation of mucinous cystadenoma of an appendix. A fortyyear-old Caucasian female patient with a history of pleuritis and recurrent pericarditis was admitted to the hospital due to acute abdomen. At that time she was taking indomethacin and colchicine due to pericarditis that was controlled only with the combination of these two drugs. The patient had elevated erythrocyte sedimentation rate (ESR), increased C-reactive protein (CRP) and normocytic anemia. Immunological tests, including antinuclear antibody, anti-neutrophil cytoplasmic antibody, rheumatoid factor, and anti-cyclic citrullinated peptide antibodies, were repeatedly negative. Emergency surgery revealed acute appendicitis with perforation and subsequent diffuse peritonitis. Histopathological examination showed acute appendicitis and mucinous cystadenoma. Following the surgery the patient did not take any drugs. Fourteen months later the patient was symptom free. Pleuritis and pericarditis in female patients are most often associated with autoimmune diseases. We assume that increased ESR and CRP with anemia detected in the patient may reflect the altered immunity that is due to mucinous cystadenoma. We believe that this report has a broader clinical impact, implying that benign tumor could alter immunity, which can lead to unusual presentation such as polyserositis.

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