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We report a case of infective endocarditis of the mitral valve, which was accompanied by pulmonary emboli traveling through an atrial septal defect. An 18-year-old male was admitted to our hospital due to a fever, polyarthritis and subcutaneous hemorrhage. Transthoracic echocardiography revealed a mobile mass and possible vegetation lodged in the mitral valve and a secundum-type atrial septal defect. Computed tomography revealed a hepatic, splenic and renal embolic infarction. During antibiotic therapy, he felt a sudden right flank pain. Follow-up computed tomography revealed a pulmonary embolic infarction that drifted through an atrial septal defect. This association is the first report, of pulmonary emboli which migrated through an atrial septal defect from the mitral valve.

Objective To compare hemorrhagic events between clopidogrel and ticagrelor in the Platelet Inhibition and Patient Outcomes (PLATO) trial. Methods We examined the FDA Medical Review. Results Compared to clopidogrel, ticagrelor significantly increased spontaneous bleeds, major bleeds, major plus minor bleeds, and major plus minor plus minimal bleeds. Ticagrelor also increased both major and fatal/life-threatening bleeds versus clopidogrel when CABG was performed between 24 and 96h after stopping medication, which was also accompanied by a larger volume of chest tube drainage and transfusions. Moreover, ticagrelor increased CABG-related bleeding versus clopidogrel in those patients who did not wait until day 5 after stopping treatment to have CABG. Additionally, compared to clopidogrel, ticagrelor increased the risk of hematuria (RR=1.91; 95% CI: 0.95–3.83), intracranial hemorrhage or subdural or other hematoma (RR 1.87; 95% CI: 1.02–3.42), subcutaneous hemorrhage, ecchymosis, hematoma (RR=1.63; 95% CI: 0.84–3.17), epistaxis (RR=1.49; 95% CI: 0.67–3.32), retroperitoneal hematoma or hemorrhage (RR=1.49; 95% CI: 0.53–4.19), gastrointestinal/anal bleed (RR=1.23; 95% CI: 0.93–1.64) and bleed/hematoma (RR=1.21, 95% CI: 1.02–1.43). Conclusions Clopidogrel is safer than ticagrelor in regard to bleeding. Additionally, ticagrelor's purported faster antiplatelet ‘offset' is substantially longer than its pharmacokinetics indicate. Considering the fact that the mortality, stent thrombosis and myocardial infarction ‘benefit' of ticagrelor have recently been challenged, and that the increase in stroke on ticagrelor has recently been shown to be worse than originally published, the decision to use ticagrelor over clopidogrel in the face of a higher risk for bleeds is not advised.