Image in Cardiology
Native mitral valve endocarditis complicated with abscess and fistulas: Diagnosis by three-dimensional transesophageal echocardiography
Endocardite de válvula mitral nativa complicada por abcesso e fístulas: diagnóstico por ecocardiografía transesofágica 3D
Ana Gabaldón-Pérez
, Rafael De la Espriella, Hector Merenciano-Gonzalez, Enrique Santas, Francisco J. Chorro
Corresponding author
Department of Cardiology, University Clinical Hospital of Valencia, Valencia, Spain
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Note the abscess at the anterolateral commissure of the mitral valve (arrow); (B) surgical specimen consisting of the mitral valve abscess; (C) TEE at 110° with three-dimensional (3D) reconstruction of the mitral valve (‘surgical’ view), showing perforation of the anterior leaflet at the A1 level and the abscess (asterisk); (D) TEE at 110° with 3D reconstruction of the mitral valve (‘surgical’ view), showing the other fistula directed toward the lateral wall of the left atrium and the abscess (asterisk); (E) TEE at 110° with 3D reconstruction of the mitral valve view from the ventricular side. Note the two fistulas in the same view; (F) TEE at 125° of the mitral valve with color Doppler showing the mitral regurgitation jets of both fistulas.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Ana Gabaldón-Pérez, Rafael De la Espriella, Hector Merenciano-Gonzalez, Enrique Santas, Francisco J. 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(A-C) Cine steady state free precession sequences (in diastole) with overlapping echocardiographic findings – similar wall thicknesses, particularly in the LV apical segments. Long-axis horizontal views enable visualization of the apex, with a clearly abnormal cavity morphology, confirming the diagnosis of apical hypertrophic cardiomyopathy, mixed form, with an ‘ace of spades’ configuration; (D-F) delayed enhancement sequences showing absence of myocardial fibrosis. 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"apellidos" => "Chorro" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Cardiology, University Clinical Hospital of Valencia, Valencia, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Endocardite de válvula mitral nativa complicada por abcesso e fístulas: diagnóstico por ecocardiografía transesofágica 3D" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3213 "Ancho" => 2917 "Tamanyo" => 1047668 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Transesophageal echocardiography (TEE) of the mitral valve at 55°. Note the abscess at the anterolateral commissure of the mitral valve (arrow); (B) surgical specimen consisting of the mitral valve abscess; (C) TEE at 110° with three-dimensional (3D) reconstruction of the mitral valve (‘surgical’ view), showing perforation of the anterior leaflet at the A1 level and the abscess (asterisk); (D) TEE at 110° with 3D reconstruction of the mitral valve (‘surgical’ view), showing the other fistula directed toward the lateral wall of the left atrium and the abscess (asterisk); (E) TEE at 110° with 3D reconstruction of the mitral valve view from the ventricular side. Note the two fistulas in the same view; (F) TEE at 125° of the mitral valve with color Doppler showing the mitral regurgitation jets of both fistulas.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">An 18-year-old male presented to the emergency department with persistent fever (up to 39<span class="elsevierStyleHsp" style=""></span>°C) and progressive fatigue. On admission, physical examination revealed heart rate of 92 bpm, temperature of 37.4<span class="elsevierStyleHsp" style=""></span>°C and a grade 4/6 pansystolic murmur at the apex radiating to the left axillary area. Complete blood count was normal, but C-reactive protein was elevated at 207 mg/l (normal 0-5 mg/l). Transthoracic echocardiography (TTE) showed an echodense mass located at the mitral annulus associated with severe mitral regurgitation. Three of four blood cultures were positive for <span class="elsevierStyleItalic">Haemophilus parainfluenzae</span>. Transesophageal echocardiography (TEE) showed an annular abscess at the anterolateral commissure measuring 16 mm×18 mm (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A and Video S1), complicated by two fistulas: one directed toward the lateral wall of the left atrium with three-dimensional (3D) effective regurgitant orifice (ORE) of 0.28 cm<span class="elsevierStyleSup">2</span> (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>C and E, Video S2) and another located more medially as a possible perforation of the anterior leaflet at the A1 level, with 3D ORE of 0.38 cm<span class="elsevierStyleSup">2</span> (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>D and E, Video S3), which together were causing severe mitral regurgitation (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>F). These echocardiographic findings were confirmed at surgery, in which resection of the anterolateral commissure (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>B) and commissurotomy were performed without intraoperarative complications and with an excellent postoperative course. Control TTE showed minimal early systolic central regurgitation, and no residual fistula was observed (Videos S4-S6).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">This case highlights the usefulness of 3D-TEE for accurate assessment of the mitral valve apparatus, as it enables cardiac surgeons to perform a comprehensive preoperative anatomical and functional assessment of this condition.</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflicts of interest" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-04-20" "fechaAceptado" => "2020-06-11" "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0025" class="elsevierStylePara elsevierViewall">The following are the supplementary material to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia><elsevierMultimedia ident="upi0010"></elsevierMultimedia><elsevierMultimedia ident="upi0015"></elsevierMultimedia><elsevierMultimedia ident="upi0020"></elsevierMultimedia><elsevierMultimedia ident="upi0025"></elsevierMultimedia><elsevierMultimedia ident="upi0030"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0015" ] ] ] ] "multimedia" => array:7 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3213 "Ancho" => 2917 "Tamanyo" => 1047668 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Transesophageal echocardiography (TEE) of the mitral valve at 55°. Note the abscess at the anterolateral commissure of the mitral valve (arrow); (B) surgical specimen consisting of the mitral valve abscess; (C) TEE at 110° with three-dimensional (3D) reconstruction of the mitral valve (‘surgical’ view), showing perforation of the anterior leaflet at the A1 level and the abscess (asterisk); (D) TEE at 110° with 3D reconstruction of the mitral valve (‘surgical’ view), showing the other fistula directed toward the lateral wall of the left atrium and the abscess (asterisk); (E) TEE at 110° with 3D reconstruction of the mitral valve view from the ventricular side. Note the two fistulas in the same view; (F) TEE at 125° of the mitral valve with color Doppler showing the mitral regurgitation jets of both fistulas.</p>" ] ] 1 => array:7 [ "identificador" => "upi0005" "etiqueta" => "Video S1" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mp4" "ficheroTamanyo" => 309440 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:5 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiography, 100°, mitral valve.</p>" ] ] 2 => array:7 [ "identificador" => "upi0010" "etiqueta" => "Video S2" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc2.mp4" "ficheroTamanyo" => 335483 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc2.flv" "poster" => "mmc2.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:5 [ "fichero" => "mmc2.m4v" "poster" => "mmc2.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiography, 87°, color Doppler of the mitral valve.</p>" ] ] 3 => array:7 [ "identificador" => "upi0015" "etiqueta" => "Video S3" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc3.mp4" "ficheroTamanyo" => 261841 "Video" => array:2 [ "mp4" => array:5 [ "fichero" => "mmc3.m4v" "poster" => "mmc3.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "flv" => array:5 [ "fichero" => "mmc3.flv" "poster" => "mmc3.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiography, 100°, color Doppler of the mitral valve.</p>" ] ] 4 => array:7 [ "identificador" => "upi0020" "etiqueta" => "Video S4" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc4.mp4" "ficheroTamanyo" => 228844 "Video" => array:2 [ "mp4" => array:5 [ "fichero" => "mmc4.m4v" "poster" => "mmc4.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "flv" => array:5 [ "fichero" => "mmc4.flv" "poster" => "mmc4.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Postoperative control transthoracic echocardiography, three-dimensional reconstruction of mitral valve.</p>" ] ] 5 => array:7 [ "identificador" => "upi0025" "etiqueta" => "Video S5" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc5.mp4" "ficheroTamanyo" => 335904 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc5.flv" "poster" => "mmc5.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:5 [ "fichero" => "mmc5.m4v" "poster" => "mmc5.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Postoperative control transthoracic echocardiography, three-dimensional reconstruction of the mitral valve.</p>" ] ] 6 => array:7 [ "identificador" => "upi0030" "etiqueta" => "Video S6" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc6.mp4" "ficheroTamanyo" => 301348 "Video" => array:2 [ "mp4" => array:5 [ "fichero" => "mmc6.m4v" "poster" => "mmc6.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "flv" => array:5 [ "fichero" => "mmc6.flv" "poster" => "mmc6.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Postoperative control transthoracic echocardiography, color Doppler of the mitral valve.</p>" ] ] ] ] "idiomaDefecto" => "en" "url" => "/08702551/0000004000000010/v1_202110050607/S0870255121003450/v1_202110050607/en/main.assets" "Apartado" => array:4 [ "identificador" => "75834" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Imagem em Cardiologia" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/08702551/0000004000000010/v1_202110050607/S0870255121003450/v1_202110050607/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255121003450?idApp=UINPBA00004E" ]
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