Advertisement

Infective Endocarditis

  • Teerapat Yingchoncharoen

Abstract

A 62-year-old man with a history of degenerative mitral valve disease for several years presented to his local primary care physician due to fever, night sweats, chills, shortness of breath, and lethargy for 1 week. He was diagnosed with viral illness and treated with azithromycin twice a day for 1 week. His fever persisted despite good compliance with antibiotics therapy. He went to see a cardiologist, where blood cultures were drawn and echocardiography was performed. His blood culture grew group B Streptococcus and transthoracic echocardiography (TTE) showed severe mitral regurgitation with possible torn chordae tendinae. He was treated with intravenous ceftriaxone and gentamicin for 1 month and referred to our institute for mitral valve surgery. Intraoperatively, degenerative mitral valve disease with ruptured chordae tendinae and vegetations at the posterior leaflet were found. He underwent successful robotically assisted mitral valve repair with a 33-mm Duran annuloplasty band (Figs. 7.1, 7.2, 7.3, 7.4, 7.5, and 7.6).

Keywords

Vegetation Infective endocarditis Paravalvular abscess Valve perforation 

Supplementary material

Video 7.1

Apical four-chamber transthoracic echocardiography (TTE) showing large vegetation attached to the posterior leaflet of the mitral valve (AVI 8904 kb)

Video 7.2

Color Doppler imaging of Fig. 7.1 demonstrated severe mitral regurgitation with an eccentric, anteriorly directed jet (AVI 2018 kb)

Video 7.3

Three-dimensional TTE showing vegetation at the posterior mitral leaflet (AVI 2539 kb)

Video 7.4

Four-chamber transesophageal echocardiography (TEE) showing flail of the P2 segment of the posterior mitral leaflet (AVI 6317 kb)

Video 7.5

Zoom view of mitral valve showing large vegetation at the posterior mitral leaflet (AVI 17801 kb)

Video 7.6

Apical four-chamber TEE showing a large vegetation attached to the anterior and posterior leaflet of the mitral valve (AVI 4594 kb)

Video 7.7

Apical four-chamber TEE with color Doppler flow imaging showing severe mitral regurgitation (AVI 837 kb)

Video 7.8

Long-axis TEE demonstrated posterior mitral leaflet vegetation and mitral-aortic intervalvular fibrosa abscess and aneurysm (AVI 4764 kb)

Video 7.9

Long-axis TEE with color Doppler flow imaging showing mild aortic insufficiency and perforation of the anterior mitral leaflet. During diastole, a mild aortic insufficiency (AI) jet was seen, which was eccentric and anteriorly directed. During systole, there was mitral regurgitation caused by leaflet perforation from a “kissing lesion.” (AVI 1713 kb)

Video 7.10

Three-dimensional (3D) TEE of the mitral valve (LA view) showing multiple vegetations (AVI 1022 kb)

310450_1_En_7_MOESM11_ESM.avi (5.4 mb)
Video 7.11 Coronary angiogram showing total occlusion of the distal left anterior descending artery. Given the angiographic features of acute cut-off appearance and the history of multiple vegetations, the finding is most likely consistent with coronary embolism from IE (AVI 5517 kb)
Video 7.12

TEE (short-axis view) demonstrating the aortic homograft with a paravalvular root abscess. Specifically, there is circumferential paravalvular issue thickening, with a more organized echolucent space adjacent to the interatrial septum (AVI 2916 kb)

Video 7.13

TEE (3-chamber, long-axis view) showing perforation of the base of the anterior mitral valve leaflet (AVI 2970 kb)

Video 7.14

TEE (3 chamber, long-axis view) with color Doppler imaging showing severe mitral regurgitation through the perforation in the base of the anterior mitral valve leaflet (AVI 1224 kb)

Video 7.15

TEE (4-chamber view) showing perforation of the base of the anterior mitral valve leaflet (AVI 2824 kb)

Video 7.16

TEE (4-chamber view) with color Doppler imaging showing severe mitral regurgitation through the perforation in the base of the anterior mitral valve leaflet (AVI 1302 kb)

Video 7.17

TEE three-dimensional reconstruction of the mitral valve (surgical view from the left atrium) demonstrating well-circumscribed perforation in the basal aspect of the middle scallop of the anterior mitral valve leaflet (A2) (AVI 426 kb)

Video 7.18

TEE image (four-chamber view) showing multiple mobile echodensities attached to both leaflets of the mitral valve, consistent with multiple vegetations (AVI 6108 kb)

310450_1_En_7_MOESM19_ESM.avi (2.6 mb)
Video 7.19 TEE images (long-axis view) again showing multiple mobile echodensities seen at both leaflets of the mitral valve, consistent with multiple vegetations (AVI 2617 kb)
Video 7.20

3D-TEE images of the surgical view of the mitral valve showing multiple vegetations (AVI 2074 kb)

Video 7.21

TEE images (four-chamber view) showing LV to RA shunts (just above the septal leaflet of the tricuspid valve) during systole, features consistent with a Gerbode defect (AVI 1880 kb)

Video 7.22

TTE, parasternal view, showing expansile submitral echolucent space consistent with ventricular pseudoaneurysm (AVI 5261 kb)

Video 7.23

TTE, apical four-chamber view, showing rocking motion of the prosthetic mitral valve consistent with prosthetic dehiscence. There is an expansile echolucent space consistent with ventricular pseudoaneurysm (AVI 4559 kb)

Video 7.24

TTE, apical two-chamber view, showing rocking motion of the prosthetic mitral valve consistent with prosthetic dehiscence. There is an expansile echolucent space consistent with ventricular pseudoaneurysm (AVI 5034 kb)

Video 7.25

TTE, subcostal view, showing mitral prosthetic dehiscence and ventricular pseudoaneurysm (AVI 2774 kb)

Video 7.26

TEE, four-chamber view, showing mobile echodensity at the cardiac crux, extending over the mitral and tricuspid annulus, as well as a central, echolucent area consistent with cardiac crux abscess (AVI 7362 kb)

Video 7.27

TEE, two-chamber view, showing extensive vegetation obstructing mitral inflow (AVI 7370 kb)

Video 7.28

TEE, short-axis view at the aortic valve level, showing communicating flow between the proximal aorta and the right ventricle, with systolic and diastolic flow consistent with an aortic-ventricular fistula (AVI 1448 kb)

Video 7.29

TEE, short-axis view at the aortic valve level, showing prosthetic aortic valve dehiscence along the posterior aspect. There are vegetations involving the aortic valve and the tricuspid valve (AVI 7312 kb)

References

  1. 1.
    Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63:e57–185.PubMedCrossRefGoogle Scholar
  2. 2.
    Murdoch DR, Corey GR, Hoen B, Miro JM, Fowler Jr VG, Bayer AS, et al. Clinical presentation, etiology, and outcome of infective endocarditis in the 21st century: the International Collaboration on Endocarditis-Prospective Cohort Study. Arch Intern Med. 2009;169:463–73.PubMedCentralPubMedCrossRefGoogle Scholar
  3. 3.
    Selton-Suty C, Celard M, Le Moing V, Doco-Lecompte T, Chirouze C, Iung B, et al. Preeminence of Staphylococcus aureus in infective endocarditis: a 1-year population-based survey. Clin Infect Dis. 2012;54:1230–9.PubMedCrossRefGoogle Scholar
  4. 4.
    Hoen B, Duval X. Clinical practice. Infective endocarditis. N Engl J Med. 2013;368:1425–33.PubMedCrossRefGoogle Scholar
  5. 5.
    Bloechlinger S, Nebiker M, Windecker S. Unusual cause of myocardial infarction and congestive heart failure in a patient with prosthetic valve endocarditis. Catheter Cardiovasc Interv. 2014;83:E69–72.PubMedCrossRefGoogle Scholar
  6. 6.
    Khan F, Khakoo R, Failinger C. Managing embolic myocardial infarction in infective endocarditis: current options. J Infect. 2005;51:e101–5.PubMedCrossRefGoogle Scholar
  7. 7.
    Unger P, Dedobbeleer C, Van Camp G, Plein D, Cosyns B, Lancellotti P. Mitral regurgitation in patients with aortic stenosis undergoing valve replacement. Heart. 2010;96:9–14.PubMedCrossRefGoogle Scholar
  8. 8.
    Bansal RC, Graham BM, Jutzy KR, Shakudo M, Shah PM. Left ventricular outflow tract to left atrial communication secondary to rupture of mitral-aortic intervalvular fibrosa in infective endocarditis: diagnosis by transesophageal echocardiography and color flow imaging. J Am Coll Cardiol. 1990;15:499–504.PubMedCrossRefGoogle Scholar
  9. 9.
    Carlson EB, Wolfe WG, Kisslo J. Subvalvular left ventricular pseudoaneurysm after mitral valve replacement: two-dimensional echocardiographic findings. J Am Coll Cardiol. 1985;6:1164–6.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag London 2015

Authors and Affiliations

  1. 1.Department of Cardiovascular MedicineCleveland ClinicClevelandUSA

Personalised recommendations