Use of transesophageal echocardiography for improving detection of valvular vegetations in subacute bacterial endocarditis

Subacute bacterial endocarditis is associated with significant morbidity and mortality. Valvular destruction, congestive heart failure, embolic phenomena, failure of medical therapy, and death are all more common in patients with echocardiographically discernible valvular lesions. Transthoracic echocardiography is often unsatisfactory for evaluation of vegetations in patients with chest wall deformities, lung disease, obesity, or prosthetic valves. The transesophageal approach affords uniformly high-quality images with excellent structural resolution. We present a case of suspected subacute bacterial endocarditis in a patient with equivocal diagnoses of vegetations on three separate transthoracic echocardiograms in whom transesophageal evaluation revealed obvious large vegetations that involved the aortic and mitral valves. Subsequent autopsy confirmed this diagnosis. The case illustrates the utility of a new imaging method for the detection of valvular vegetations. In view of the prognostic implications of detected vegetations, transesophageal echocardiography probably should be performed on all patients with suspected subacute bacterial endocarditis and equivocal results by transthoracic study.