Septic pulmonary and systemic embolism in tricuspid endocarditis

Abstract

A 28-year-old woman presenting with fever was referred to our hospital and diagnosed as septic pulmonary embolism secondary to tricuspid valve endocarditis. Although antibiotic therapy was initiated, she further showed multiple complications including Janeway lesions and cerebral infarctions, suggestive of septic systemic embolism. Transoesophageal echocardiography detected a right-to-left shunt through a patent foramen ovale (PFO). The patient was successfully treated with surgical tricuspid valvuloplasty and PFO closure. Paradoxical systemic embolism may occur in patients with septic pulmonary embolism through the PFO.

Paradoxical embolisation to the brain in right-sided infective endocarditis and patent foramen ovale in a pregnant woman

“…Most PFOs are clinically silent and are either discovered incidentally or through poststroke evaluation. Typically, PFOs are associated with left-to-right intracardiac shunting; however, in certain conditions where right-heart pressures overcome the left, such as severe TR, right-to left shunting may develop 5 9. In the setting of a PFO with right-to-left shunt, paradoxical embolisation from the right heart to the central nervous system may potentially occur 5.…”

“…Right-sided IE (RSIE) is typically associated with septic pulmonary emboli and related pulmonary complications 3. However, in the presence of a right-to-left intracardiac shunt, paradoxical embolisation into the systemic circulation can occur 4 5. One potential catastrophic complication of this phenomena is cerebrovascular embolisation leading to stroke.…”

Systemic septic emboli in tricuspid endocarditis due to an atrial communication with a right-to-left shunt

“…Although rare, a previously undiagnosed patent foramen ovale (PFO) found incidentally during the diagnosis of tricuspid valve IE is well documented 5–8. However, there have only been seven previous reports of right-sided IE complicated by paradoxical emboli through a PFO 9–15. The first such report described a previously clinically insignificant PFO becoming relevant in the setting of tricuspid valve IE with septic embolisation to the liver.…”

Complete occlusion of the left pulmonary artery and paradoxical cerebral embolus from tricuspid valve endocarditis

“…The patient was clinically stable and proceeded with a planned course of 6 weeks of antibiotics, weekly chest CT for surveillance and transitioned from heparin to apixaban until hospital day 19, when she developed lethargy and right sided hemiparesis with CT evidence of a left-sided haemorrhagic stroke. Given isolated right-sided endocarditis and patent foramen ovale, the patient was felt to have experienced haemorrhagic conversion of an ischaemic stroke secondary to paradoxical embolus from the known TV vegetation 4 5. Repeat TTE demonstrated progression of right-to-left ventricular shunt with worsened TV regurgitation, progressive right atrial enlargement and widened PFO.…”