International Journal of Cardiology 185 (2015) 249
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
3-D assessment of infective endocarditis with anterior mitral valve perforation and flail posterior leaflet Thomas C. Butler ⁎, John F. Sedgwick, Darryl J. Burstow The University of Queensland and The Prince Charles Hospitals, Brisbane, Australia
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Article history: Received 11 January 2015 Accepted 21 February 2015 Available online 2 March 2015 Keywords: 3-D transoesophageal echocardiography Infective endocarditis Mitral valve
A 66 year old man presented with a febrile illness and class III NYHA dyspnea, with blood cultures positive for Staphylococcal epidermidis. This was in the context of lethargy and night sweets over the preceding two months. He had reported a recent decline in his exercise tolerance with worsening dyspnea. Clinical examination revealed a pan systolic murmur at the left apex consistent with mitral regurgitation. A chest X-ray performed was consistent with pulmonary venous congestion. In addition, a chest and abdominal CT scan identified revealed a wedge shaped hypodensity consistent with splenic infarction with splenomegaly and small bilateral pleural effusions. Given the very high clinical suspicion for complicated infective endocarditis, transesophageal echocardiography was performed. Initial 2-D
⁎ Corresponding author. E-mail address: [email protected] (T.C. Butler).
http://dx.doi.org/10.1016/j.ijcard.2015.02.098 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
imaging demonstrated a flail posterior mitral leaflet with severe regurgitation flanked by a large vegetation (panel A and supplementary Movies 1 and 2). In addition, an anterior leaflet perforation was suspected and subsequently confirmed on 3-D imaging with precise anatomical localization and sizing of the defect (panel A, B and supplementary Movie 3). The irregularity and extent of the infected flail posterior leaflet was illustrated, with the vegetation measuring (31 mm by 19 mm). Cardiac surgery was indicated for cardiac failure complicating severe mitral regurgitation. Pathological inspection of the mitral valve confirmed the A2 scallop perforation (panel D, anterior leaflet labeled “A” and posterior leaflet labeled “P”) and a large vegetation associated with destruction of a flail posterior leaflet. The native valve was excised and replaced with a 29 mm mosaic mitral prosthesis. Post operatively the patient recovered well after completing 6 weeks of targeted antimicrobial therapy. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ijcard.2015.02.098. Conflict of interest The authors report no relationships that could be construed as a conflict of interest.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
3-D assessment of infective endocarditis with anterior mitral valve perforation and flail posterior leaflet Thomas C. Butler ⁎, John F. Sedgwick, Darryl J. Burstow The University of Queensland and The Prince Charles Hospitals, Brisbane, Australia
a r t i c l e
i n f o
Article history: Received 11 January 2015 Accepted 21 February 2015 Available online 2 March 2015 Keywords: 3-D transoesophageal echocardiography Infective endocarditis Mitral valve
A 66 year old man presented with a febrile illness and class III NYHA dyspnea, with blood cultures positive for Staphylococcal epidermidis. This was in the context of lethargy and night sweets over the preceding two months. He had reported a recent decline in his exercise tolerance with worsening dyspnea. Clinical examination revealed a pan systolic murmur at the left apex consistent with mitral regurgitation. A chest X-ray performed was consistent with pulmonary venous congestion. In addition, a chest and abdominal CT scan identified revealed a wedge shaped hypodensity consistent with splenic infarction with splenomegaly and small bilateral pleural effusions. Given the very high clinical suspicion for complicated infective endocarditis, transesophageal echocardiography was performed. Initial 2-D
⁎ Corresponding author. E-mail address: [email protected] (T.C. Butler).
http://dx.doi.org/10.1016/j.ijcard.2015.02.098 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
imaging demonstrated a flail posterior mitral leaflet with severe regurgitation flanked by a large vegetation (panel A and supplementary Movies 1 and 2). In addition, an anterior leaflet perforation was suspected and subsequently confirmed on 3-D imaging with precise anatomical localization and sizing of the defect (panel A, B and supplementary Movie 3). The irregularity and extent of the infected flail posterior leaflet was illustrated, with the vegetation measuring (31 mm by 19 mm). Cardiac surgery was indicated for cardiac failure complicating severe mitral regurgitation. Pathological inspection of the mitral valve confirmed the A2 scallop perforation (panel D, anterior leaflet labeled “A” and posterior leaflet labeled “P”) and a large vegetation associated with destruction of a flail posterior leaflet. The native valve was excised and replaced with a 29 mm mosaic mitral prosthesis. Post operatively the patient recovered well after completing 6 weeks of targeted antimicrobial therapy. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ijcard.2015.02.098. Conflict of interest The authors report no relationships that could be construed as a conflict of interest.
