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Mitral valve ring abscess and ventricular pseudoaneurysm are rare complications of infective endocarditis. We describe the case of a 58-year-old man who was admitted to our hospital with sepsis caused by Staphylococcus aureus and in whom tricuspid and mitral valve endocarditis developed within 2 weeks. Despite widespread antibiotic therapy, the endocarditis proceeded to form a mitral valve ring abscess and a left ventricular pseudoaneurysm. The diagnosis was set by repeated multiplane transesophageal echocardiography and confirmed by heart surgery.

Background and Objective: Recently the tilting table test (tilting up to 70 degrees angle) has established itself for the diagnosis of neurocardiogenic syncope (NS). Usually patients with bradycardic arrhythmias or asystole are treated by pacemaker implantation. But if the syncope is of neurocardiogenic aetiology other therapeutic alternatives must be chosen. We here report on seven patients in whom a pacemaker had been implanted in the treatment of syncopes, in ignorance of their neurocardiogenic aetiology, yet they had recurred., Patients and Methods: Pacemakers had been implanted in eight patients: two with sick sinus syndrome, three with sinus bradycardia, one with brady-tachyarrhythmia, one with asystole and one with Mobitz-type 2 degrees AV block. All patients continued to have syncopes, when sitting or standing, months to years after the pacemaker implantation. The tilting table test (up to 30 min at an angle of 70 degrees) was positive in all patients. There was no case of pacemaker malfunction., Results: One patient declined further treatment. The remaining seven patients were symptom-free in the tilting table test on various medications: theophylline up to 2 x 350 mg, metoprolol up to 2 x 100 mg or disopyramide 3 x 100 mg., Conclusion: Patients with syncope while sitting or standing should undergo the tilting table test to determine whether the cause is neurocardiogenic so that pacemaker implantation can be avoided. The majority of patients with NS can be successfully treated by drugs. But in some patients pacemaker implantation may have to considered if drug treatment has failed.

Standing in long-lasting operations can be a trigger for neurocardiogenic syncopes for the personal in the operating theatre. We report on a 37-year-old surgeon who suffered since childhood from more than 100 syncopes and presyncopes. That was the reason for him to think of giving up his profession. The head-up tilt-test proved the mechanism of a neurocardiogenic syncope. No further syncope has occurred for 16 months during the therapy with theophyllin.