Spontaneous drainage of paravalvular abscess diagnosed by transesophageal echocardiography

Paravalvular abscesses, which occur in up to 30% of cases of native valve endocarditis, are being detected with increasing frequency with the use of transesophageal echocardiography. Abscesses of the mitral aortic intervalvular fibrosa have been described but only in association with native or prosthetic aortic valve endocarditis. We describe a patient with native mitral valve endocarditis complicated by an abscess in the fibrosa. A 51-year-old diabetic man presented with Staphylococcus aureus mitral valve endocarditis. A transesophageal echocardiographic study done 8 days after admission revealed two large masses at the base of the anterior mitral leaflet with extension into the fibrosa consistent with a paravalvular abscess that was not detected by precordial echocardiography. A repeat transesophageal echocardiographic study done 20 days after admission showed spontaneous drainage of the abscess and a subsequent fistula between the left atrium and left ventricle. This case highlights the important role that transesophageal echocardiography has in suspected and known cases of endocarditis. Its major advantage of delineating posterior cardiac structures allowed accurate diagnosis and serial evaluation of this previously unreported complication of endocarditis.     

Echocardiographic detection of aortic valve ring abscesses

Valve ring abscess complication of infective endocarditis increases the expected morbidity and mortality rates of patients, but is seldom recognized by available noninvasive techniques. In our study, two-dimensional echocardiography successfully detected valve ring abscesses in eight patients with infective endocarditis affecting aortic valve prosthesis. Echocardiography showed the perivalvular abscess as an echo-free space in all patients. Prosthetic vegetations were seen in the only patient who had a biological prosthesis and excessive prosthetic rocking was observed in cases with severe aortic regurgitation. In two patients, the first echocardiographic examination showed an echo-free space without evident clinical signs of endocarditis or significant valve regurgitation. Severe aortic insufficiency and congestive heart failure followed the enlargement of the echo-free space. Valve replacement was required in all but one patient. The echocardiographic findings were confirmed at surgery. In one patient, the extension of the abscess to the interventricular septum was not detected by the echocardiography.     

Transesophageal echocardiographic identification of an aortic root to right atrial fistula in a patient with acute streptococcal aortic valve bacterial endocarditis.

We describe the case of a patient with acute aortic valve endocarditis complicated by aortic insufficiency, perivalvular abscess, and aortic root to right atrial fistula caused by Streptococcus pneumoniae bacterial infective endocarditis. Although typically of low sensitivity for the diagnosis of myocardial abscess and similar complications of infective endocarditis, transthoracic echocardiogram successfully identified this relatively uncommon complication that was later confirmed by transesophageal echocardiography and at time of operation.     

Aortic valve endocarditis caused by Salmonella species

We report a case of aortic valve endocarditis caused by an uncommon pathogen, Salmonella species. Transthoracic echocardiography proved to be inadequate to show the valvular destruction. Transesophageal echocardiography was instrumental in establishing the diagnosis of endocarditis by documenting aortic vegetations with attendant tissue damage extending beyond the valve leaflets (ie, subvalvular and perivalvular damage). The findings were anatomically confirmed at surgery, which also revealed an aortic root–right ventricular fistula and several aortic ring abscesses. Early implementation of transesophageal echocardiography is strongly recommended in patients with suspected endocarditis.© 1999 John Wiley & Sons, Inc. J Clin Ultrasound 27:45–48, 1999     

An unusual case of acquired ventricular septal defect as a complication of aortic valve endocarditis: echocardiographic delineation of multiple subvalvular complications in one patient.

We describe a patient with unusual echocardiographic features of prosthetic aortic valve endocarditis. Transesophageal echocardiography in this patient demonstrated a large multiloculated aortic root abscess extending to mitral-aortic intervalvular fibrosa, a high acquired ventricular septal defect, paravalvular aortic regurgitation caused by aortic valve dehiscence, and anterior mitral valve leaflet perforation.     

Teddy Bear in the Heart

In a patient with native aortic valve endocarditis, transoesphageal echocardiography yielded a teddy bear appearance which is not reported so far. A perivalvular abscess (right ear), the superior vena cava in cross section (left ear) and the dilated (post-stenotic) aortic root (face) made up the teddy bear. This was not a cuddlesome toy but an ominous sign. The genesis of perivalvular abscess as well as the role of transoesphageal echocardiography in its diagnosis and treatment are briefly reviewed.     

Aorto‐pulmonary fistula as a late complication of multiple valve replacement after Streptococcus Bovis endocarditis in a patient with occult colon carcinoma

We report a case of aorto‐pulmonary fistula following multiple valve surgery in a patient with colon carcinoma who had had recurrent episodes of Streptococcus Bovis endocarditis. Diagnosis was made by transesophageal echocardiography and aortography. Patient underwent emergency percutaneous implantation of an aortic endoprosthesis, but he continued to deteriorate and the fatal outcome could not be changed. This case underscores the importance of examination of gastrointestinal tract in patients with Streptococcus Bovis endocarditis. © 2009 Wiley Periodicals, Inc. J Clin Ultrasound, 2009     

Early surgical intervention in culture-negative endocarditis of the aortic valve complicated by abscess in an infant: A case report

BACKGROUNDSurgical therapy of infective endocarditis (IE) involving aortic valves and mitral valves is widespread. However, there are few reports concerning patients with culture-negative endocarditis complicated by the appearance of comorbid valvular perforation and abscess. Therefore, real-time surveillance of changes in cardiac structure and function is critical for timely surgical management, especially in patients who do not respond to medical therapy.CASE SUMMARYHere, we report an atypical case in a 9-mo-old infant without congenital heart disease but with symptoms of intermittent fever and macular rashes. Physical examination, laboratory tests, and electrocardiograms suggested a diagnosis of IE, although the result of blood cultures was exactly negative. After treatment with antibiotic drugs, the patient got a transient recovery. On the 9^th day, we proceeded with continuous echocardiogram due to fever again and the results revealed aortic valve abscess with perforation, regurgitation, vegetation, and pericardial effusion. Intraoperative monitoring revealed aortic valve perforation, presence of apothegmatic cystic spaces below the left coronary cusp of the aortic valve, and severe aortic valve regurgitation. Aortic valve repair was performed by autologous pericardial patch plasty. The patient was discharged after 4 wk of treatment and no complications occurred after surgery.CONCLUSIONOur case demonstrated the necessity of serial echocardiography monitoring for possible adverse symptoms of IE in pediatric patients.     

Congenital bicuspid aortic valve enodocarditis with multiple subvalvular complications and an acquired membranous ventricular septal defect.

We report a case with echocardiographic demonstration of native congenital bicuspid aortic valve endocarditis with multiple subaortic complications. Transesophageal echocardiography in this case revealed large vegetations with multiloculated aortic paravalvular abscess around the cusps; a high-acquired restrictive membranous ventricular septal defect with vegetations extending to the tricuspid leaflets and paravalvular aortic regurgitation caused by aortic leaflet perforation.     

Perforation of the anterior mitral leaflet caused by aortic valve endocarditis: diagnosis by two-dimensional, transesophageal echocardiography and color flow Doppler.

Perforation of the mitral valve as a result of aortic valve endocarditis is rare. Recognition of such abnormality is very important before surgical intervention. Diagnosis is very difficult by either invasive or noninvasive techniques. This report stresses the role of echocardiography in evaluating this rare abnormality. Perforation of the anterior mitral valve leaflet developed in our patient as a complication of aortic valve endocarditis. The perforation was suggested by the surface echocardiogram (as an interruption of the leaflet continuity) and by the color flow Doppler (which suggested turbulent flow at the area of suspected interruption). The perforation was confirmed during surgery by transesophageal echocardiography and alerted the surgeon to repair, rather than replace, the valve.     

Intra-aortic balloon pump associated with dynamic left ventricular outflow tract obstruction after valve replacement for aortic stenosis.

An unstable patient with critical aortic stenosis had an intra-aortic balloon pump placed preoperatively for hemodynamic support and alleviation of symptoms. After separation from cardiopulmonary bypass following aortic valve replacement, the patient was hypotensive with increased pulmonary artery pressures. Transesophageal echocardiography revealed left ventricular outflow tract obstruction associated with systolic anterior motion of the mitral valve and severe mitral regurgitation. This pathophysiology was present when ventricular systole was preceded by balloon counterpulsation, but was absent during unassisted systole. This case report demonstrates a potentially significant untoward effect of intra-aortic balloon pump augmentation after aortic valve replacement for aortic stenosis. The timely diagnosis of this iatrogenic condition in the operating room permitted the prompt implementation of appropriate management strategies and avoided unnecessary surgical intervention.     

Unusual cases of infective endocarditis.

We report 2 patients with unusual cases of infective endocarditis. The first patient had a large, mural vegetation on left ventricle that was diagnosed with transthoracic echocardiography; and the second patient had a large, mobile vegetation in the descending prosthetic aorta with an abscess cavity around the vessel, diagnosed by transesophageal echocardiography. This report confirms the usefulness of transthoracic and transesophageal echocardiography in the diagnosis and management of uncommon cases of endocarditis.     

ProgressiveStaphylococcus lugdunensis endocarditis despite antibiotic treatment

A 68-year old man with fever chills and a diastolic murmur was diagnosed with aortic-valve endocarditis caused by coagulase-negative Staphylococcus lugdunensis. The clinical condition initially improved with antibiotic therapy. On day seven, transoesophageal echocardiography revealed large abscesses extending from the aortic root to the left ventricular wall. Emergency cardiac surgery was performed successfully and a stentless bioprosthetic valve was inserted. S. lugdunensis endocarditis is known for its aggressive clinical course with valve destruction, abscess formation and embolic complications despite appropriate antibiotics. Antibiotic treatment alone is associated with a high mortality rate which can be reduced by early valve replacement.     

A case of iatrogenic aortic valve leaflet perforation after closure of a ventricular septal defect

Aortic regurgitation caused by leaflet perforation is most frequently seen in association with infective endocarditis that involves the aortic valve. There have been occasional reports of iatrogenic aortic regurgitation caused by aortic valve injury after cardiac surgery with the use of the transaortic approach or invasive cardiac procedures. Suture-related aortic valve injury can develop during periaortic cardiac surgery, but this has been very rarely reported. Inadvertent injury to an aortic valve leaflet caused by a stitching needle or surgical forceps can produce leaflet perforation with aortic regurgitation. This report describes a case of aortic regurgitation that was caused by iatrogenic aortic valve leaflet perforation, and this occurred in a 22-year-old woman who underwent repair of a ventricular septal defect (VSD) 15 years previously. Transthoracic echocardiography (TTE) showed a defect located at the aortic annulus close to the infundibular septum on a two-dimensional echocardiographic study and we observed an eccentric jet flow into the left ventricle in early diastole on the continuous wave and color flow Doppler studies. A small perforation in the body of the right aortic cusp and mild to moderate aortic regurgitation were confirmed by the use of transesophageal echocardiography (TEE) and ascending aortography.     

ED identification of cardiac septal abscess using conduction block on ECG

A case of cardiac septal abscess in a patient with a porcine bioprosthetic aortic valve who gradually developed a complete atrioventricular block on successive electrocardiograms (ECG) is reported. Emergency physicians should consider endocarditis with septal abscess in a patient with a prosthetic heart valve who presents with fever and a new conduction defect on ECG.     

An unusual cause of diastolic mitral regurgitation as a result of sterile perforation of the mitral valve.

We report the case of a 50-year-old man in whom a supracristal ventricular septal defect led to aortic regurgitation and, thus, to consecutive sterile perforation of the anterior mitral leaflet, culminating in the development of severe systolic and diastolic mitral regurgitation. Aortic regurgitation as a result of valve prolapse caused by a supracristal (conal) ventricular septal defect is a well-known phenomenon. The same is true for the origin of mitral jet lesions in patients with infective endocarditis of the aortic valve. As of yet, there have been no reports about the acquisition of mitral valve perforations in patients without the history of vegetations. Moreover, the occurrence of diastolic mitral regurgitation is usually associated with atrioventricular pressure reversal, a phenomenon that was not present in our patient. The unique comorbidity was easy to detect with Doppler echocardiography, supported by transesophageal 2-dimensional and dynamic 3-dimensional echocardiography for preoperative surgical treatment.     

Infective endocarditis of the aortic valve complicated by massive pericardial effusion and rupture of a sinus of valsalva into the right atrium.

Infective endocarditis (IE) of the aortic valve is most commonly associated with perivalvular invasion and intracardiac fistula formation, which sometimes give rise to unpredictable clinical events. Massive pericardial effusion and aorticocardiac fistula are very rare complications of IE. We present a case in which IE of the aortic valve was initially associated with massive pericardial effusion requiring drainage and later complicated by rupture of a sinus of Valsalva with a fistula into the right atrium without formation of aneurysm. To our knowledge, the concurrent occurrence of these two events in a patient with IE has not been previously reported.     

Aortic dissection with fistula to left atrium: diagnosis by transesophageal echocardiography with successful repair.

The aorta-atria fistula is an infrequent complication of aortic dissection, and it is rarely diagnosed before death. A 41-year-old man who 8 years previously had undergone prosthetic aortic valve replacement had an aortic dissection complicated by aorta-left atrial fistula. This patient had acute left heart failure associated with a systolic and diastolic murmur at the lower left sternal border suggesting an aortic prosthetic malfunction. The cardiac diagnosis was made with transesophageal echocardiography and Doppler color flow imaging; it was notable that the cardiac lesions were not detected by transthoracic echocardiography. On the basis of the echocardiographic findings, the patient underwent successful emergency replacement of the dissecting ascending aorta with closure of the aorta-left atrial fistula. Transesophageal echocardiography is the procedure of choice for defining this abnormality. In this case a prompt surgical repair consisting of replacement of the affected segment of the aorta with the prosthesis and closure of the fistula provided optimum resolution of the clinical situation.     

Intraoperative diagnosis of aortic pseudoaneurysm with transesophageal echocardiography

A pseudoaneurysm of the ascending aorta is a rare complication of aortic valve endocarditis that requires prompt diagnosis. Several imaging strategies can be used; however, transesophageal echocardiography (TEE) has been utilized more frequently due to its superior resolution in detection of aortic valve complications. This case presents a patient with prosthetic valve dysfunction in which intraoperative TEE was used to diagnose a previously undetected aortic pseudoaneurysm, thus leading to a change in surgical management.     

Major dehiscence of infected aortic valve prosthesis with “rocking motion” but without diastolic paravalvular regurgitation

We present a case of a 66-year-old patient with infective endocarditis of an aortic valve bioprosthesis with major dehiscence and extensive “rocking motion” but without any diastolic paravalvular regurgitation as assessed with radiography and transesophageal echocardiography.