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Clinical Images

Mitral Leaflet Vegetations in 3D

Edward Samuel Roberto M.D., Thein Aung M.D., Mukul Chandra M.D. FACC

October 30, 2015

A 39-year-old male presented to the emergency department with pain, swelling, erythema, and tenderness in his left calf. He endorsed a 5-day history of fatigue, intermittent fevers and chills, gait abnormalities, and an episode of transient visual loss in his left eye. Past medical history was significant for spinal osteomyelitis.

In the ED his vital signs were stable. He was evaluated for a DVT, however both D-dimer and ultrasound were negative. CBC revealed an elevated WBC count (15.7) with left shift. The elevated white count along with left leg findings led to an admitting diagnosis of cellulitis. The patient was started on IV Vancomycin and admitted for further investigation on account of intense pain out of proportion to exam. Blood cultures, CRP, and ESR were ordered. An MRI brain was ordered as well for suspicion of gait abnormalities and transient visual field loss. 

Shortly after admission he began to have intermittent sharp chest pain. Troponins were elevated and a new-onset holosystolic murmur was auscultated over the left fifth intercostal space. Heart catheterization revealed no significant occlusions, only mild plaque deposition, the most severe being 40% stenosis in the left circumflex. MRI brain revealed multiple small zones of acute cerebellar infarct, as well as additional foci in the parietal cortex and one in the inferior left occipital lobe. Blood cultures returned growing S. Viridans and S. Epidermidis. Echocardiography was performed to evaluate for endocarditis due to fevers and elevated white count. 

Transesophageal echo revealed left atrial enlargement and a pair of 1.5 cm masses at the mitral valve leaflets. The vegetations were highly mobile with prolapse into the left atrial cavity in systole, accompanied by a severe central jet of mitral regurgitation [Fig. 2]. The diagnosis was revised to infective bacterial endocarditis and the patient was continued on six weeks of IV Vancomycin prior to a mitral valve repair. 

 

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Current capabilities in three-dimensional processing allowed for greater precision in determining the size and localization of these vegetations to both anterior (A2-mid leaflet) and posterior (P2-mid leaflet) mitral valve areas. In contrast to the standard 2D echocardiographic window, 3D enhancement was able to further augment the physician’s surgical approach to repairing mitral valve pathology and the repair was conducted successfully. 

 

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References:

1.  Prendergast BD, Tornos P. Valvular heart disease: Changing concepts in disease management. Surgery for Infective Endocarditis, Who and When? Circulation, 2010; 121:1141-1152
2.  Habib G, Hoen B, Tornos P, et al. Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009). European Heart Journal, 2009; 30: 2369-2413

Author Bios:

Edward Samuel Roberto M.D. is a first year internal medicine resident at Wright State University Boonshoft School of Medicine in Dayton, OH. Dr. Roberto is passionate about a career of academic teaching and research, Osler, and earnestly pursuing Fellowship in Cardiovascular medicine. 

Thein Aung M.D. is a second year Cardiovascular Disease Fellow at Wright State University Boonshoft School of Medicine. 

Mukul Chandra M.D. FACC is Clinical Associate Professor of Medicine at Wright State University Boonshoft School of Medicine.