case_images: PMC11415862_01
case_images: CASE 1 - A 75-year-old man presented feeling generally unwell with fever. Staphylococcus aureus was isolated from blood cultures (see text). LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle; AAo, ascending aorta.
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case_images: PMC11415862_01_fcvm-11-1459833-g001.jpg
case_images: F1
case_images: Cardiac CT was performed: An in-plane view (Figure 1A) of the aortic valve demonstrated a low-density soft tissue vegetation on all three cusps and a pseudoaneurysm (arrow) which communicated with the left coronary sinus (HU 420). Oblique coronal (Figure 1B) and axial (Figure 1C) views demonstrated that the vegetation was attached to both sides of the aortic valve cusps and showed the presence of a small pseudoaneurysm (arrow) that had been missed on TTE. TOE images (Figure 1D) taken in the mid-oesophageal aortic valve short axis view (ME AV SAX view) failed to accurately differentiate aortic valve calcification from small vegetations. There was a presumed small pseudoaneurysm communicating with the left coronary cusp (arrow) but its extent could not be determined.
case_images: PMC11415862_02
case_images: CASE 2 - A 77-year-old man with a history of transcatheter aortic valve implantation (TAVI) presented with a sore throat, diarrhoea, and a temperature of 40 C. Staphylococcus aureus was isolated from blood cultures (see text). RA, right atrium; RVOT, right ventricular outflow tract; RV, right ventricle; LA, left atrium; LV, left ventricle; AAo, ascending aorta.
case_images: fcvm-11-1459833-g002.jpg
case_images: PMC11415862_02_fcvm-11-1459833-g002.jpg
case_images: F2
case_images: The oblique coronal (Figure 2A) and 3-chamber (Figure 2B) views demonstrated a low-density soft tissue vegetation (arrow) with a Hounsfield Unit (HU) value 80 attached to the TAVI leaflets. An in-plane view (Figure 2C) showed that the vegetation (arrow) involved all three cusps of the implanted valve. In the initial TOE images (Figure 2D) taken in the ME AV SAX view, the TAVI nitinol stent frame obscured adequate prosthetic valve leaflet evaluation (arrow) and aortic root involvement could not be established.
case_images: PMC11415862_03
case_images: CASE 3 - A 79-year-old man presented with shortness of breath and fever. Blood cultures grew Staphylococcus aureus (see text). RA, right atrium; RV, right ventricle; LA, left atrium; LV, left ventricle; AAo, ascending aorta.
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case_images: PMC11415862_03_fcvm-11-1459833-g003.jpg
case_images: F3
case_images: The axial 4-chamber (Figure 3A) and oblique sagittal 2-chamber (Figure 3B) views demonstrated a low-density soft tissue (HU 78) vegetation (arrow) attached to a calcified posterior mitral valve leaflet. An oblique coronal view (Figure 3C) confirmed these findings and highlighted possible involvement of the anterior leaflet. Preceding TOE images in the mid-oesophageal (ME) 4-chamber (Figure 3D), ME 2-chamber (Figure 3E) and ME 3-chamber (Figure 3F) views demonstrated a large heterogenous calcified mass attached to the posterior mitral valve leaflet (arrows) consistent with a vegetation.
case_images: PMC11415862_04
case_images: CASE 4 - A 79-year-old man with metallic mitral and aortic valve prostheses undergoing treatment for IE remained febrile and unwell despite appropriate guideline recommended antibiotic therapy (see text). RA, right atrium; RV, right ventricle; LA, left atrium; LV, left ventricle; AAo, ascending aorta.
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case_images: PMC11415862_04_fcvm-11-1459833-g004.jpg
case_images: F4
case_images: Cardiac CT was performed: Axial (Figure 4A) and in-plane (Figure 4B) views demonstrated a multi-lobulated thick walled paravalvular pseudoaneurysm (asterisks) (HU 231) which extended posteriorly and laterally to the sewing ring of the valve prosthesis. Oblique sagittal 2-chamber (Figure 4C) demonstrated additional inferior extension of the pseudoaneurysm (asterisk). Preceding TOE images taken from the ME mitral commissural (Figure 4D), ME 2-chamber (Figure 4E) and ME 3-chamber (Figure 4F) views showed a likely paravalvular pseudoaneursym (asterisk) but its extent or size could not be adequatly determined leading to a CT being performed.
case_images: PMC11415862_05
case_images: CASE 5 - A 53-year-old man presented with fever, dyspnoea and confusion on a backgound history of intravenous drug use. Blood cultures grew Staphylococcus aureus (see text). RA, right atrium; RV, right ventricle; MPA, mean pulmonary artery; LA, left atrium; LV, left ventricle.
case_images: fcvm-11-1459833-g005.jpg
case_images: PMC11415862_05_fcvm-11-1459833-g005.jpg
case_images: F5
case_images: Cardiac CT was performed: Axial 4-chamber (Figure 5A) and oblique coronal (Figure 5B) views showed a low density soft tissue vegetation (arrow) (HU 59) attached to the tricuspid valve leaflets with an associated perforation (arrow) over the posterior tricuspid valve leaflet (Figure 5B). The wide field of view reconstructions (Figures 5C and 5D) showed bilateral foci of cavitating consolidation consistent with septic emboli (asterisks). AV SAX (Figure 5F) views demonstrated a large mobile heterogenous mass consistent with a large vegetation. A cardiac CT and a flash ECG-gated aorta were arranged to further elucidate leaflet morphology, assess for extra-cardiac complications and evaluate the coronary arteries prior to surgical intervention.
case_images: PMC11415862_06
case_images: CASE 6 - A 71-year-old man presented with fever, confusion and fatigue. Enterococcus faecalis was isolated from blood cultures (see text). RA, right atrium; RVOT, right ventricular outflow tract; RV, right ventricle; MPA, mean pulmonary artery; LA, left atrium; LV, left ventricle; AAo, ascending aorta.
case_images: fcvm-11-1459833-g006.jpg
case_images: PMC11415862_06_fcvm-11-1459833-g006.jpg
case_images: F6
case_images: An oblique coronal (Figure 6A) view demonstrated a paravalvular fistula (arrow) extending from the region of the aortic valve non-coronary cusp (NCC) and left ventricular outflow tract into the right atrium (RA). An oblique axial view (Figure 6B) demonstrated a pseudoaneurysm (asterisk) (HU 283) originating from the right coronary cusp (RCC). An oblique in-plane view (Figure 6C) demonstrated both the pseudoaneurysm (asterisk) originating from the RCC and the fistulous connection (arrow) between the NCC and RA. Preceding TTE images in the apical 5-chamber view (Figure 6D) demonstrated a likely communication between the aortic valve and LVOT. Blood flow through this communication was documented with both apical 5-chamber colour Doppler (Figure 6E) and subcostal 4-chamber pulsed wave Doppler (Figure 6F).
case_images: PMC11415862_07
case_images: CASE 7 - A 69-year-old man presented with decompensated heart failure. Blood cultures were negative (see text). LAD, left anterior descending artery; LCX, left circumflex artery; RCA, right coronary artery; LA, left atrium; RA, right atrium; RVOT, right ventricular outflow tract.
case_images: fcvm-11-1459833-g007.jpg
case_images: PMC11415862_07_fcvm-11-1459833-g007.jpg
case_images: F7
case_images: Cardiac CT 3D reconstructed images demonstrated a large and almost circumferential pseudoaneurysm (Figure 7A) (arrows) which originated from the aortic valve left coronary cusp (LCC) adjacent to the origin of left main stem coronary artery (Figures 7B and 7C). TOE images in the ME AV SAX view (Figure 7D) had shown dehiscence of the surgical bioprosthetic valve with a large pseudoaneurysm that appeared to be communicating with the LCC. The CT scan in this instance had been requested to evaluate not only the coronary arteries prior to cardiac surgery but also establish the extent of the pseudoaneurysm prior to surgical correction.