Bioprosthetic MV endocarditis

 

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This parasternal long axis TTE view in a persistently febrile individual shows a large mass on the bioprosthetic mitral valve that is moving in an out of the valve plane, consistent with a large vegetation.

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Additional views shows the MV ring appears to be well seeded without significant rocking motion.

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A zoomed in view in the apical 4 chamber shows the mass appears friable and multilobulated as well as highly mobile, raising significant concern for embolism.

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Color Doppler in this zoomed in 3 chamber view shows no significant regurgitation or perivalvular leak. With a mass of this size, obstruction causing functional mitral stenosis is a concern. Note the turbulent inflow in diastole.
 
TEE was later performed to assess for involvement of other valves and to better assess the bioprosthetic valve just prior to surgical intervention.

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As seen in the TEE, the mass is complex and appears to involve both bioprosthetic mitral leaflets. As in the TTE the atria are both massively dilated and the RV is also dilated. These were from the preexisting condition leading to valve replacement.

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By TEE we also do not see evidence of significant MR or valve leaflet perforation in additional views. Note the turbulence in diastole. No other valve were found to be involved.

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A live 3D TEE view shows the mass in relation to the mitral valve. We are looking at the valve from the left atrium. The valve itself is still well seeded. The mass occupies a large portion of the mitral valve orifice and prolapses fully into the atria in systole and into the ventricle during diastole.