case_images: PMC11178404_01
case_images: Select images from the (a, b) initial transesophageal echocardiogram performed upon admission to the referring hospital and (c, d) follow-up transthoracic echocardiogram performed upon transfer to our tertiary academic medical center. (a) Midesophageal short-axis view demonstrating thickened bioprosthetic aortic valve leaflets with vegetation (arrow). (b) Midesophageal four-chamber view showing large vegetation along the anterior leaflet of the mitral valve. (c) Parasternal short-axis view of bioprosthetic aortic valve in diastole with color flow suggestive of aortic valve regurgitation (arrow). (d) Apical five-chamber view in diastole showing high-velocity flow in the left ventricular outflow tract consistent with aortic valve regurgitation (arrow).
case_images: CRIC2024-7550403.001.jpg
case_images: PMC11178404_01_CRIC2024-7550403.001.jpg
case_images: fig1
case_images: Given evidence of native mitral valve endocarditis and a bioprosthetic AV that was not fully visualized, a TEE was performed that demonstrated the mitral valve vegetation but also visualized a 1.3 x 1.8 cm vegetation involving the AV bioprosthesis (Figures 1(a) and 1(b)) with what was described as a small amount of paravalvular regurgitation without signs of abscess. On the day of admission, a repeat TTE was performed that showed interval elevation in gradients across the AV bioprosthesis (mean gradient 40 mmHg, as compared to 20 mmHg) with mild-moderate regurgitation (Figures 1(c) and 1(d)), a large vegetation along the anterior mitral valve leaflet extending along the aorto-mitral curtain with possible leaflet perforation and at least mild regurgitation, as well as severe left atrial dilation and pulmonary hypertension.
case_images: Transesophageal echocardiogram obtained approximately two weeks into hospital stay. (a-c) Bulky vegetation on the mitral valve extending along the aorto-mitral curtain with associated mitral regurgitation and possible leaflet perforation that are not well-characterized. (d) High-velocity flow in the LVOT concerning for regurgitation, as well as (e) an abnormal lucency along the aorto-mitral curtain consistent with abscess and possible fistula (yellow arrow). (f) There was high-velocity flow associated with the abscess by color Doppler (white arrow); however, in the context of tachycardia and adjacent LVOT flow, it was difficult to discern the timing of flow in the cardiac cycle.
case_images: CRIC2024-7550403.002.jpg
case_images: PMC11178404_01_CRIC2024-7550403.002.jpg
case_images: fig2
case_images: TEE was performed to better characterize the AV bioprosthesis and aortic root prior to surgery (Figure 2).
case_images: Color M-mode was used to differentiate flow along the aorto-mitral curtain from aortic regurgitation in the LVOT. The temporal resolution from M-mode clearly defines continuous, turbulent flow within the space adjacent to the aorto-mitral curtain, consistent with fistula between the aorta and left atrium. Flow within the LVOT occurs predominantly in systole, which is inconsistent with aortic regurgitation.
case_images: CRIC2024-7550403.003.jpg
case_images: PMC11178404_01_CRIC2024-7550403.003.jpg
case_images: fig3
case_images: Color M-mode was used to provide the temporal resolution necessary to delineate the location and timing of flow with respect to the cardiac cycle (Figure 3).