Bacterial endocarditis complicating pregnancy: case report and systematic review of the literature

Contemporary management of infective endocarditis in pregnancy

INTRODUCTION

Infective endocarditis (IE) during pregnancy is a rare condition that is associated with a high level of morbidity and mortality. The epidemiology, diagnosis, treatment, and prognosis have changed significantly in the last two decades. The declining incidence of rheumatic heart disease, improved life expectancy with congenital heart disease, advances in cardiac surgery and cardiac devices, rise in resistant microorganisms, complications of the opioid epidemic, and increasing maternal age are some of the many factors contributing to these changes.

AREAS COVERED

This article explores existing literature on the topic including case reports, case series, registry data, and clinical guidelines. The focus of this article is the evolving epidemiology, predisposing factors and preventative measures, clinical presentation, investigation, management, and potential complications of IE in pregnancy.

EXPERT OPINION

Robust prospective data on the management of IE in pregnancy is lacking, and obtaining these data will be very challenging. It is imperative that international registries are used to provide data on best clinical practices and inform future clinical guidelines. Multimodal imaging should be incorporated in the investigation of complicated cases. A multidisciplinary approach to the management of this rare and life-threatening condition is essential to ensure the best outcomes for both the mother and the fetus.

Infective Endocarditis during Pregnancy-Keep It Safe and Simple!

The diagnosis of infective endocarditis (IE) during pregnancy is accompanied by a poor prognosis for both mother and fetus in the absence of prompt management by multidisciplinary teams. We searched the electronic databases of PubMed, MEDLINE and EMBASE for clinical studies addressing the management of infective endocarditis during pregnancy, with the aim of realizing a literature review ranging from risk factors to diagnostic investigations to optimal therapeutic management for mother and fetus alike. The presence of previous cardiovascular pathologies such as rheumatic heart disease, congenital heart disease, prosthetic valves, hemodialysis, intravenous catheters or immunosuppression are the main risk factors predisposing patients to IE during pregnancy. The identification of modern risk factors such as intracardiac devices and intravenous drug administration as well as genetic diagnostic methods such as cell-free deoxyribonucleic acid (DNA) next-generation sequencing require that these cases be addressed in multidisciplinary teams. Guiding treatment to eradicate infection and protect the fetus simultaneously creates challenges for cardiologists and gynecologists alike.

Percutaneous debulking of tricuspid vegetations due to infectious endocarditis in pregnancy: a case report

Infective endocarditis is a rare but serious disease with increasing prevalence in women of childbearing age because of the opioid epidemic. Therefore, it is an increasingly frequent pregnancy complication. The gold standard of treatment is intravenous antibiotics with surgery reserved for refractory cases. However, pregnancy complicates decisions about the risk and timing of surgery. AngioVac represents a percutaneous alternative to surgical intervention. Here, we present a case of a 22-year-old G2P1001 woman with a history of intravenous drug use and infective endocarditis who continued to show signs and symptoms of septic pulmonary emboli despite management with intravenous antibiotics. The patient was deemed not to be a surgical candidate while pregnant and had an AngioVac procedure at 30 2/7 weeks of gestation with the removal of tricuspid vegetations. The patient was delivered via cesarean delivery at 32 5/7 weeks of gestation because of a nonreassuring fetal heart tracing. The patient's tricuspid valve was replaced on postpartum day 16. This case demonstrates that AngioVac can be safely used in the third trimester of pregnancy and may be considered in consultation with a multidisciplinary team for the management of infective endocarditis refractory to antibiotic treatment as an interim measure until surgery can be safely performed.

Staphylococcus Aureus Infective Endocarditis: JACC Patient Pathways

A 19-year-old female patient presented with Staphylococcus aureus infective endocarditis, with suspected subdural brain hemorrhage, disseminated intravascular coagulopathy, and septic renal as well as spleen infarcts. The patient had extensive vegetations on the mitral and tricuspid valves and underwent urgent mitral and tricuspid repair. This paper discusses the clinical case and current evidence regarding the management and treatment of Staphylococcus aureus endocarditis.

Bicuspid Aortic Valve in Pregnancy Complicated by Aortic Valve Vegetation, Aortic Root Abscess, and Aortic Insufficiency

A 39-year-old patient presented to our Labor and Delivery unit with fever and nausea in the context of recent bacteriuria. She was found to be in sepsis due to an incidental bicuspid aortic valve (BAV) complicated by aortic valvular vegetations, severe aortic insufficiency, and aortic root abscess, requiring an emergent cesarean section. Three days after delivery, the patient successfully underwent a mechanical aortic valve replacement and root reconstruction. In this case report, medical, surgical, and anesthetic management of parturient patients with BAV are discussed. The management of this congenital valvulopathy and vasculopathy is complicated by the extensive hemodynamic and cardiovascular derangements that occur during pregnancy.

Staphylococcus Aureus Infective Endocarditis: JACC Patient Pathways

A 19-year-old female patient presented with Staphylococcus aureus infective endocarditis, with suspected subdural brain hemorrhage, disseminated intravascular coagulopathy, and septic renal as well as spleen infarcts. The patient had extensive vegetations on the mitral and tricuspid valves and underwent urgent mitral and tricuspid repair. This paper discusses the clinical case and current evidence regarding the management and treatment of Staphylococcus aureus endocarditis.

Maternal and fetal outcomes associated with infective endocarditis in pregnancy

INTRODUCTION

Infective endocarditis (IE) is a rare but serious infection complicating pregnancy. Little is known about IE management and outcomes in this population.

METHODS

The National Readmissions Database was used to obtain data between October 2015 and October 2018. Billing codes identified admissions for IE in female patients of reproductive age. Demographic characteristics, comorbidities, and outcomes were compared between a) patients with maternity-associated and non-maternity associated IE, and b) obstetric patients who delivered with and without IE. Weighted regressions were used to examine outcomes in adjusted models.

RESULTS

We identified 12,602 reproductive-aged female patients with a diagnosis of IE, of which 382 (weighted national estimate: 748) were maternity-associated. Of these cases, 117 (weighted national estimate: 217) occurred during a delivery admission. Compared to patients with non-maternity-associated IE, maternity-associated infection was associated with younger age (mean 29.0 vs. 36.6 years, P < 0.001), Medicaid coverage (72.5% vs. 47.2%, P < 0.001), and drug use (76.2% vs. 59.8%, P < 0.001). Mortality was comparable (8.1% vs. 10.6%, aRR = 1.03, 95% CI 0.71-1.48). Compared to patients delivering without IE, IE complicating delivery was associated with worse maternal and fetal outcomes, including maternal mortality (17.2% vs. <0.01%, aRR = 323.32, 95% CI 127.74-818.37) and preterm birth (55.7% vs. 10.1%, aRR = 3.61, 95% CI 2.58-5.08).

CONCLUSION

Maternity-associated IE does not appear to confer additional risk for adverse outcome over non-maternity-associated infection. Patients delivering with IE have worse maternal and fetal outcomes than those whose deliveries are not complicated by IE.

Infective endocarditis in pregnancy from 2009 to 2019: the consequences of injection drug use

BACKGROUND

Endocarditis during pregnancy carries a maternal mortality of up to 30%, but prior publications do not reflect the current opioid epidemic.

CASE PRESENTATIONS

We reviewed our institution's infective endocarditis registry from 2009 to 2019 and identified 19 females with endocarditis during pregnancy in order to compare our contemporary outcomes with historical reports. In our cohort, intravenous drug use was reported in all cases, and the most common pathogen was Staphylococcus (74%) followed by Serratia (13%). The tricuspid valve was involved in 18 (95%) patients, and contrary to prior reports, all but two patients were managed conservatively with antibiotics alone. Maternal and infant mortality (5% and 0%, respectively) were lower in our cohort compared to all previous reviews.

CONCLUSION

We conclude that the better outcomes seen in this report are likely due to the younger age of the patients and the more frequent right-sided valvular involvement.

SUMMARY

This review highlights contemporary outcomes in endocarditis during pregnancy. We review historical case reports in light of the opioid epidemic. We observed more Staphylococcus, more right-sided valvular involvement, and more conservative management as well as improved maternal and foetal mortality.

Infective endocarditis due to Streptococcus agalactiae in the puerperal period

Streptococcus agalactiae, also known as group B Streptococcus, is a species of bacteria occasionally detected in the vagina and/or rectum of pregnant women. This report describes the case of a 33-year-old woman who developed infective endocarditis on puerperal day 17, owing to group B Streptococcus, and required lifesaving surgery. The patient was rushed to our hospital with chief complaints of fever and fatigue. After hospitalization, antibiotics were administered; however, the symptoms did not improve. Following a detailed examination, vegetation was found in the heart, suggestive of infective endocarditis. Surgical removal of the vegetation improved the patient's condition. The development of group B Streptococcus infection and infective endocarditis in a pregnant woman with no risk factors is rare. This case confirms that this patient's life was saved by a timely diagnosis and appropriate therapeutic intervention.

Tricuspid valve endocarditis in pregnancy: a case report and review of the literature

Infective endocarditis (IE) is a rare complication in pregnancy that is associated with significant morbidity and mortality to both mother and fetus. We present a case of a 27-year-old female at 22-weeks gestation with a history of intravenous drug abuse (IVDA) who developed methicillin sensitive Staphylococcus aureus tricuspid valve endocarditis with persistent bacteremia and septic emboli necessitating tricuspid valve extirpation. Four days later, worsening decompensated heart failure required cesarean section at 23w5d. Although the patient's volume status and dyspnea improved significantly, fetal demise occurred 9 days after operative delivery.

Maternal Bacteremia Caused by Staphylococcus Aureus With a Focus on Infective Endocarditis

Background

Sepsis is an important cause of morbidity and mortality in the pregnant patient. Injection drug use in pregnant populations has led to increased cases of bacteremia and infective endocarditis (IE) due to Staphylococcus aureus. We describe all cases of S. aureus bacteremia and IE among admitted pregnant patients at our hospital over a 6-year period.

Methods

This was a retrospective review of pregnant patients hospitalized with S. aureus bacteremia between April 2013 and November 2019. Maternal in-hospital mortality and fetal in-hospital mortality were the primary outcomes measured; the secondary outcome was the rate of 6-month maternal readmission.

Results

Twenty-seven patients were included; 15 (56%) had IE. The median (interquartile range [IQR]) age was 29 (25-33) years; 22 (82%) patients had methicillin-resistant S. aureus. Infection onset occurred at a median (IQR) of 29 (23-34) weeks' gestation. Twenty-three (85%) mothers reported active injection drug use, and 21 (78%) were hepatitis C seropositive. Fifteen (56%) mothers required intensive care unit (ICU) care. Twenty-two (81%) patients delivered 23 babies; of the remaining 5 mothers, 3 (11%) were lost to follow-up and 2 (7%) terminated pregnancy. Sixteen (73%) babies required neonatal ICU care, and 4/25 (16%) infants/fetuses died during hospitalization. One (4%) mother died during hospitalization, and 7/26 (27%) mothers were readmitted to the hospital within 6 months for infectious complications.

Conclusions

Injection drug use is a modifiable risk factor for S. aureus bacteremia in pregnancy. Fetal outcomes were poor, and mothers were frequently readmitted secondary to infection. Future targeted interventions are needed to curtail injection drug use in this population.

Pregnancy and cardiovascular disease

Cardiovascular disease complicates 1-4% of pregnancies - with a higher prevalence when including hypertensive disorders - and is the leading cause of maternal death. In women with known cardiovascular pathology, such as congenital heart disease, timely counselling is possible and the outcome is fairly good. By contrast, maternal mortality is high in women with acquired heart disease that presents during pregnancy (such as acute coronary syndrome or aortic dissection). Worryingly, the prevalence of acquired cardiovascular disease during pregnancy is rising as older maternal age, obesity, diabetes mellitus and hypertension become more common in the pregnant population. Management of cardiovascular disease in pregnancy is challenging owing to the unique maternal physiology, characterized by profound changes to multiple organ systems. The presence of the fetus compounds the situation because both the cardiometabolic disease and its management might adversely affect the fetus. Equally, avoiding essential treatment because of potential fetal harm risks a poor outcome for both mother and child. In this Review, we examine how the physiological adaptations during pregnancy can provoke cardiometabolic complications or exacerbate existing cardiometabolic disease and, conversely, how cardiometabolic disease can compromise the adaptations to pregnancy and their intended purpose: the development and growth of the fetus.

Infective Endocarditis in a Third Trimester Pregnant Woman: Team Work Is the Best Option

Infective endocarditis in pregnancy may have a misleading presentation and carries a high-risk of complications for both the mother and her infant. When urgent valve surgery is required, the fetal risk relative to cardiopulmonary bypass is challenging requiring a multidisciplinary management. We report the case of a pregnant woman with infective endocarditis on a bicuspid aortic valve who was successfully treated by a 2-step strategy including cardiac surgery. (Level of Difficulty: Intermediate.)

Managing Heart Disease in Pregnancy

Cardiac disease is an important cause of mortality in pregnancy. It has the potential to remain undiagnosed and may present with cardiovascular decompensation during pregnancy, at the time of delivery, or immediately postpartum. It can have long-term implications to the life of the affected women and their families. This review summarises the current knowledge of the incidence, prevalence, and management of pregnancy-related cardiovascular disease in women presenting preconceptionally or during pregnancy.

Subacute Infective Endocarditis of Aortic Valve During Pregnancy

Bacterial infective endocarditis is a rare but a life-threatening infection during pregnancy. Infective endocarditis during pregnancy is often associated with a congenital heart condition or an earlier history of rheumatic heart disease. In pregnant women with infective endocarditis, the maternal and fetal mortality rate can reach as high as 33% and 29%, respectively. In most cases, infective endocarditis runs a subacute course and involves the mitral valve, nonetheless, rarely it can involve the aortic valve as well. We are documenting a rare case of subacute infective endocarditis in a 26-year-old pregnant female with severe aortic stenosis with associated multiple systemic emboli. The patient was managed by urgent cesarean section at 35 weeks of gestation followed by aortic valve replacement; there was no maternal or fetal mortality. This case report highlights the importance of early diagnosis, and timely management of infective endocarditis in pregnant women to prevent maternal and fetal death.

Multivalvular infective endocarditis in pregnancy presenting with septic pulmonary emboli

A 33-year-old woman presented at 36 weeks gestation with worsening respiratory distress. A CT-pulmonary angiogram was performed to rule out a massive pulmonary embolism; instead, this identified extensive septic pulmonary emboli throughout both lung fields. Given the continuing maternal deterioration, a non-elective caesarean section was performed. A transoesophageal echocardiogram identified multiple large cardiac valve vegetations on both sides of her heart with an associated aortic root abscess. She responded well to a 6-week course of intravenous antibiotics.

Infective endocarditis in pregnancy: Case report and review of the literature

Infective endocarditis in pregnancy is associated with high maternal and fetal morbidity and mortality and is estimated to complicate approximately 1 in 100,000 pregnancies. We report the case of a 33-year-old patient who presented at 30 weeks and 3 days gestation in her third pregnancy. The patient described a 3 week history of feeling generally unwell, an episode of temporary speech disturbance, right shoulder tip pain, left subscapular pain on inspiration and chest discomfort. Investigations included an echocardiogram, which revealed a large mobile mass on the aortic coronary cusp and a small mass on the non-coronary cusp. There was significant aortic regurgitation. Blood cultures were positive for staphylococcus lugdunensis. A diagnosis of infective endocarditis was made. The patient deteriorated, with worsening cardiac function, and proceeded to have a caesarean section on day 7 of admission. Her baby had multiple limb abnormalities, subsequently diagnosed as arthrogryposis multiplex congenita. Aortic valve replacement with a mechanical valve was then performed on day 3 post partum. The patient recovered well post operatively and was discharged home with her baby on day 45 post partum. The commonest complications of IE are congestive cardiac failure, perivalvular extension and systemic embolization. The management of infective endocarditis in pregnancy is similar to that of the non-pregnant however there is high foetal mortality associated with cardiopulmonary by-pass for cardiac surgery. The patient described here developed staphylococcus lugdunensis infective endocarditis, which is a rare but aggressive causative organism in infective endocarditis. Infective endocarditis in pregnancy is a rare but serious condition with significant fetal and maternal morbidity and mortality. Early diagnosis with a multidisciplinary team approach is essential to improve outcomes.

Pregnancy and postpartum infective endocarditis: a systematic review

The objective of this review was to describe the clinical characteristics, risk factors, and outcomes of infective endocarditis (IE) in pregnancy and the postpartum period. We conducted a systematic review of Ovid MEDLINE, Ovid Embase, Web of Science, and Scopus from January 1, 1988, through October 31, 2012. Included studies reported on women who met the modified Duke criteria for the diagnosis of IE and were pregnant or postpartum. We included 72 studies that described 90 cases of peripartum IE, mostly affecting native valves (92%). Risk factors associated with IE included intravenous drug use (14%), congenital heart disease (12%), and rheumatic heart disease (12%). The most common pathogens were streptococcal (43%) and staphylococcal (26%) species. Septic pulmonary, central, and other systemic emboli were common complications. Of the 51 pregnancies, there were 41 (80%) deliveries with survival to discharge, 7 (14%) fetal deaths, 1 (2%) medical termination of pregnancy, and 2 (4%) with unknown status. Maternal mortality was 11%. Infective endocarditis is a rare, life-threatening infection in pregnancy. Risk factors are changing with a marked decrease in rheumatic heart disease and an increase in intravenous drug use. The cases reported in the literature were commonly due to streptococcal organisms, involved the right-sided valves, and were associated with intravenous drug use.

Valve disease in pregnancy

Maternal cardiac disease is a major cause of non-obstetric morbidity and accounts for 10-25% of maternal mortality. Valvular heart disease may result from congenital abnormalities or acquired lesions, some of which may involve more than one valve. Maternal and fetal risks in pregnant patients with valve disease vary according to the type and severity of the valve lesion along with resulting abnormalities of functional capacity, left ventricular function, and pulmonary artery pressure. Certain high-risk conditions are considered contraindications to pregnancy, while others may be successfully managed with observation, medications, and, in refractory cases, surgical intervention. Communication between the patient׳s obstetrician, maternal-fetal medicine specialist, obstetrical anesthesiologist, and cardiologist is critical in managing a pregnancy with underlying maternal cardiac disease. The management of the various types of valve diseases in pregnancy will be reviewed here, along with a discussion of related complications including mechanical prosthetic valves and infective endocarditis.

[High risk infective endocarditis embolism during pregnancy: Medical or surgical management?]

A 22-year-old pregnant woman was seen at 14 weeks of pregnancy for infective endocarditis with a vegetation of 15 mm and wide mobility, which affected the native mitral valve accompanied by severe valvular insufficiency. Antibiotic treatment was given for 4 weeks despite the embolism risk. Due to persistence of vegetation size and after considering the fetal and maternal risk, the surgical procedure was favored. We decided to perform valvuloplasty and removal of lesion at 18 weeks of pregnancy. Fetal protection techniques were used and a bioprosthesis was placed before attempting a repair. The postoperative follow-up was satisfactory, achieving a successful birth by cesarean section at 30 weeks.

Cardiovascular disasters in pregnancy

Cardiovascular emergencies in pregnancy are rare but often catastrophic. This article reviews the diagnosis and management of venous thromboembolism, aortic dissection, acquired heart disease and cardiomyopathy, acute myocardial infarction, and cardiac dysrhythmias in the setting of pregnancy. It also reviews updated resuscitation guidelines for cardiac arrest and perimortem cesarean section.

Tricuspid valve endocarditis during the second trimester of pregnancy

Bacterial endocarditis in pregnancy is rare, usually resulting from preexisting cardiac lesions or intravenous drug use. We present an interesting case of tricuspid valve endocarditis in a pregnant woman and raise important points in the management of this condition during pregnancy.

Infectious endocarditis during pregnancy, problems in the decision-making process: a case report

Infective endocarditis in pregnancy has a low incidence, often being associated with a previous history of rheumatic or congenital heart disease. In most reports the disease tends to run a subacute course and to appear more frequently in the third trimester of pregnancy. We present the case of a 36-year-old woman with large vegetations on the mitral valve due to infective endocarditis detected at the 32^nd week of her first pregnancy. The difficulties in selecting the appropriate management strategy, particularly optimal time and mode of delivery, optimal time and type of valve surgery, are emphasized.

[Severe acute left heart failure with pulmonary edema following cesarean section]

BACKGROUND

Severe left heart failure shortly after delivery in a previously asymptomatic young woman can be caused by a peripartum cardiomyopathy, an exacerbation of valvular heart disease due to both congenital or acquired etiologies, a sustained chronic tachyarrhythmia (tachycardiomyopathy), a fulminant pulmonary embolism, or an infective endocarditis.

CASE STUDY

2 days following cesarean section, a 36-year-old primipara without known previous heart disease suffered from severe left heart failure with pulmonary edema (Figure 1) due to an acute bacterial aortic valve endocarditis. The infecting organisms were beta-hemolytic group A streptococci. After diagnosis could be confirmed by conventional Doppler echocardiography and by transesophageal echocardiography (Figures 2 and 3), the clinical situation of the patient stabilized in a few days under an initial antibiotic regimen with vancomycin and gentamicin, diuretics and catecholamines, followed by diuretics and ACE inhibitor. 14 days after cesarean delivery, aortic valve replacement could be performed under hemodynamically stable conditions.

CONCLUSION

Although postpartal endocarditis is rarely described in the era of peripartum antibiotic prophylaxis, it should be considered in the differential diagnosis of patients with heart failure or fever in pregnancy, following delivery or cesarean section. The prognosis of peripartal endocarditis as a life-threatening disease is determined by an accurate and immediate diagnosis.

Our patients do not need endocarditis prophylaxis for genitourinary tract procedures: insights from the 2007 American Heart Association guidelines

The 2007 American Heart Association guidelines for the prevention of infective endocarditis have dramatically reduced both the types of eligible procedures and the types of eligible cardiac lesions that require prophylaxis. Antibiotic prophylaxis to prevent infective endocarditis is not indicated for any patient undergoing obstetric and/or gynaecological procedures, not even for patients with underlying cardiac lesions with the highest risk of developing complications from endocarditis. This sharp departure from previously published guidelines relies on the recognition that endocarditis is more likely to develop from "randomly occurring" bacteremia (e.g., from brushing teeth) than from invasive procedures and that antibiotic prophylaxis has not been proven to be effective. A short discussion on enterococcal infections associated to obstetric and gynaecological procedures and therapeutic implications is presented.

Infective endocarditis during pregnancy: case report

A 29-year-old woman was transferred at 31 weeks gestation for management of infective endocarditis (IE). Echocardiography demonstrated vegetations on aortic valve and severe mitral regurgitation. Blood cultures were positive for Streptococcus sanguis. Due to impending hemodynamic collapse, a cesarean section was performed followed by aortic valve replacement and mitral valve repair with a patch of bovine pericardium. At 10-month review, both mother and baby are doing well.

Tailoring systematic reviews to meet critical priorities in maternal health in the intrapartum period

Health care practitioners and researchers commonly call for greater reliance on evidence as a means to achieve improvement in quality of care. Systematic reviews provide a means to accelerate the use of evidence-based clinical interventions and public health practices. The extent to which these time- and resource-intensive systematic reviews currently address critical maternal health priorities in the intrapartum period is unclear. This analysis summarises key maternal health and research priorities, maps these priorities to existing reviews, identifies gaps in the literature that can be addressed with systematic reviews, and highlights key methodological concerns in conducting systematic reviews. The analysis draws on published data on maternal morbidities and an overview of 108 systematic reviews in Medline in the past 5 years using the MeSH terms 'Delivery, Obstetric,' to draw the links between health priorities, research priorities, existing evidence and missing evidence. Key causes of morbidity during labour and delivery in the United States include haemorrhage, pre-eclampsia and eclampsia, obstetric trauma and infection. Analyses of maternal morbidity and mortality suggest that key concerns include racial and ethnic disparities in health outcomes and the prevention of adverse events. Systematic reviews, however, generally tend to focus on the reduction of harms associated with interventions, are frequently limited to randomised designs, and do not address issues of health disparities. The results suggest that advances in evidence-based care in maternal health require that systematic reviews address issues of prevention of adverse events, include a larger variety of study designs when necessary and pay closer attention to health disparities.

Infective endocarditis of aortic valve during pregnancy: a case report

Infective endocarditis during pregnancy is uncommon but very serious. A 31-year-old woman in the 36th week of second pregnancy was admitted to a hospital because of fever, weakness, chest pain, painful skin over her right leg and dyspnea. Transthoracic echocardiography showed aortic valve vegetation and severe aortic regurgitation. Transesophageal echocardiography revealed a 18 mmx6 mm mobile vegetation, attached to the right coronary cusp. Emergency cesarean section followed with a delivery of a healthy baby. Cardiopulmonary bypass with subsequent aortic replacement with bioprosthesis was initiated immediately after cesarean section. Early echocardiographic examination and 6 months after surgery revealed normal function of aortic valve bioprosthesis and normal LV function. Clinical recognition and early echocardiographic diagnosis followed urgent simultaneous cesarean section and aortic valve replacement was lifesaving for both mother and fetus.

Infective puerperal endocarditis caused by Escherichia coli

Presentation is made of a rare case of infective puerperal endocarditis involving the native mitral valve in a young puerpera after cesarean section, without a history of pre-existing heart disease, inflammation focus or intravenous drug abuse.

Valvular heart disease in pregnancy

Women with valvular disease who are pregnant or planning to conceive require careful evaluation and management. Pregnancy is associated with normal physiologic changes that can aggravate many valvular conditions and may require the initiation or increase of cardiovascular medications to manage fluid overload or arrhythmias. Most women will tolerate pregnancy and delivery without major complication, though some types of valvular heart disease are poorly tolerated and require more intensive management, or even termination of the pregnancy. In addition, patients at risk of thromboembolism and those who have prosthetic cardiac valves require anticoagulation. The decision regarding the choice and intensity of anticoagulation requires careful balance between the individual risks of thrombosis and bleeding in the mother and harm to the fetus.

Valvular Heart Disease and Pregnancy

Pregnancy in patients with valvular heart disease (VHD) continues to pose a challenge to both physicians and their patients and could be associated with an unfavorable maternal as well as fetal outcome. The purpose of this paper is to review the available clinical data and provide recommendations for the management of patients with VHD during gestation.

Evidence for posttranscriptional regulation of the multi K homology domain protein vigilin by a small peptide encoded in the 5' leader sequence

Vigilin, a K homology (KH) protein has been found in all eukaryotic species studied. It has a unique structure of 14-15 consecutively arranged KH domains which apparently mediate RNA-protein binding. Cloning and sequencing of the mouse vigilin cDNA confirmed that the amino acid sequences of vertebrate vigilins are highly conserved and contain conserved sequence motifs of nuclear import and export sequences. The human and murine vigilin mRNAs carry two alternatively spliced 5' exons. In the 5' leader region of one of the splice variants, variant 1A, we found an upstream open reading frame (uORF) highly conserved between mouse and human. Here we present for the first time evidence that a 13 amino acid long peptide encoded by this uORF is an inhibitor of vigilin expression operating on a posttranscriptional level. We propose that the two structurally different 5' leader sequences of the human vigilin mRNA are involved in the regulation of vigilin biosynthesis.