A perturbation of T-cell repertoire is strongly associated with the recurrence of acute coronary events, conceivably playing a key pathogenetic role.

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An 87-year-old woman was admitted to our Cardiology Department with symptoms and signs of acute congestive heart failure and fever. She had a long history of hypertension and chronic atrial fibrillation. Transthoracic echocardiography showed a large (>10 mm) and mobile mitral valve vegetation, prolapsing into the left ventricular inflow tract, with severe mitral regurgitation due to a perforation in the posterior leaflet, in a mitral valve with fibro-calcific degeneration. Mitral regurgitation was hemodynamically significant and a moderate-to-severe pulmonary hypertension was observed. Tissue Doppler Imaging recorded at the level of the vegetation detected its incoherent motion and measured the peak antegrade velocity, which was found to be almost four times higher than that sampled at the lateral mitral annulus. Blood cultures were negative for both aerobic and anaerobic microbes. During hospitalization, the patient developed a sudden onset of left-side hemiplegia. Diffusion-weighted magnetic resonance imaging demonstrated multiple hyperintense lesions involving both hemispheres, suggestive of a cardioembolism. Diagnosis of fungal endocarditis was made and a treatment with fluconazole was started. Successive echocardiograms showed a decrease in the size and mobility of the mitral vegetation, and an increase in its echo intensity. However, in view of the systemic conditions severely affected, the patient was treated conservatively and died 3 months later. In our patient echocardiography played a key role for a better definition of the clinical course. In this context, Tissue Doppler Imaging might provide an adjunctive parameter for the prediction of embolic risk from endocardial vegetations: the peak antegrade velocity recorded at the level of the vegetation. However, before being adopted in clinical setting, this parameter should be validated by adequately powered prospective studies.