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We describe a case of a 64–years–old man, outwardly healthy, presented with dyspnoea for 2–3 months and weight loss, coincident Co–Vid. Lung CT scan showed massive PULMONARY EMBOLISM. Echocardiography showed LONE PULMONARY VALVE INFECTIVE ENDOCARDITYS with large mobyle vegetations swinging between RVOT and pulmonary artery. Streptococcus Gallolyticus was identified on blood culture (often related with colorectal neoplasm). Given targeted antibiotic therapy, a surgical opinion was obtained: advised trial of medical management. Patient underwent a colonscopy, because of the causing germ: a neoplasm of rectal posterior side was found, hystological examination revealed an adenocarcinoma. MNR demonstrated a solid rectal lesion protruding in the lumen, infiltrating muscle and adipose tissue, but not pelvic organs. Team discussion with surgeons and oncologists: indication at neoadjuvant therapy before heart valve surgery. After 12 days of antibiotics a new TOE and CT scan were performed and revealed enlargement of valvular vegetations with severe pulmonary regurgitation and also PE warsened. After new surgical opinion, has been given indication of valve replacement. A Magna Ease bioprostetic valve was implanted; the native valve appeared completely destroyed and histological exam showed white fragments including cusps, granulocytes and bacteria, no growth at the culture. No complications obseved in the post operative period, regular echo follow up. The patient underwent neoadjuvant therapy and then surgery to remove the colorectal mass. Lone pulmonary valve infective endocarditis is a rare disease (1–2%), especially without history of immunodeficiency or drug abuse, we should look for a cause of persistent bacteraemia. Bacteraemia is a frequent condition in presence of colorectal neoplasm or IBD, mostly enterococchi or S.Gallolitycus. Septic pulmonary embolism is a frequent complication. Following guidelines, surgery should be considered only if there is no response to antibiotic therapy, extended tricuspid valve vegetations, recurrent pulmonary embolism. Valve vegetations> 10mm are predictor of poor response to ab therapy and pulmonary embolism.

We report the case of a 50–year–old man without previous medical hystory who was admitted to our department for recurrent syncopes for several months. Throughout the 24 hours ECG Holter it has been underlined several advanced atrioventricular block episodes, hence the patient underwent to definitive pacemaker implant. After 3 months, due to sustained ventricular tachycardia, the patient incurred a out–of–hospital cardiac arrest; the patient was subjeced to cardio pulmonary resuscitation with the restoration of the sinus rithm following defibrillation. Unfortunatly, due to the resuscitation maneuvers, sternal fracture resulted. During the hospitalization in the Cardiology department, he underwent coronary angiography wich showed non significant lesions. Cardiac Magnetic Resonance was also performed among the tests. The examination was found to be particularly hard to understand due to the presence of the sternal injury that deformed the pectus and affected dynamics of the right ventricle, causing systolic bulging of the subtricuspid region of the right ventricular wall. During the dynamic sequences, there was a mild bi–ventricular reduction in systolic function. In post contrast imaging, extended transmural LGE of the basal interventricular septum and right ventricular wall, as well as multifocal involvement of the left ventricle were found. Examination was not of univolcal interpretation: the patient was tranferred to another Center to perform MR PET wich was found to be strongy suggestive of sarcoidosis, later confirmed by extra cardiac biopsy. For this reason an ICD upgrade was performed along side the immunosoppressive therapy. Sarcoidosis is an inflammatory disease characterized by the presence of noncaseous granulomas in one or more organs or tissues; at the cardiac level it can “mimic” different cardiomyopathies as an insidious diagnosis. The presence of a post–traumatic pectus excavatum leads to dyskinesia of the rignt venticular wall, reduction of the bi–ventricular systolic funcion combine with an extensive late enhancement could suggest arrhytmogenic dysplasia with bi–ventricular involvement. However, by focusing on the clinical presentation (in particular the onset charaterized by unexplained advanced AV block in a young and healthy subjet and subsequent ventricular arrhytmias), through a multimodal and multidisciplinary imaging approach it was posible to diagnose sarcoidosis with cardiac involvement and refer the patient to adequate therapy.