International Journal of Cardiology xxx (2014) xxx–xxx

IJCA-17930; No of Pages 3

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International Journal of Cardiology

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Letter to the editor

Comprehensive assessment of complications of infective endocarditis by3D transesophageal echocardiography

Sanjeev Bhattacharyya, Toufan Bahrami, Shelley Rahman-Haley ⁎Department of Cardiology & Echocardiography Laboratory, Harefield Hospital, London, United KingdomDepartment of Cardiothoracic Surgery, Harefield Hospital, London, United Kingdom

⁎ Corresponding author at: Department of Cardiology &Harefield Hospital, Hill End Road, Harefield UB9 6JH, UK.

E-mail address: S.RahmanHaley@rbht.nhs.uk (S. Rahm

http://dx.doi.org/10.1016/j.ijcard.2014.04.0290167-5273/© 2014 Published by Elsevier Ireland Ltd.

Please cite this article as: Bhattacharyya S, eechocardiography, Int J Cardiol (2014), http:

a r t i c l e i n f o

Article history:

Received 13 March 2014Accepted 2 April 2014Available online xxxx

Keywords:Infective EndocarditisThree Dimensional EchocardiographyComplications

the mitral-aortic intervalvular fibrosa to the mid-portion of anteri-or mitral valve leaflet (arrow). Bulging of base of anterior mitralvalve leaflet (seen from atrium) due to abscess collection withinthe leaflet is seen (arrow) (Fig. 1, Panel D). The patient underwenturgent aortic valve replacement with debridement of the abscess.Peri-operative images to show correlation with 3D TEE. A long, mo-bile vegetation attached to non-coronary cusp. (Fig. 2Panel A) andan abscess cavity on ventricular side of anterior mitral valve leaflet(Fig. 2, Panel B).

To the Editor,

Complications of infective endocarditis (IE) including aorticroot abscess, leaflet perforation and embolism are associated withincreased mortality andmorbidity and therefore guidelines recom-mend early surgery [1]. Although two-dimensional echocardiogra-phy (2D) is the first line investigation, three-dimensional (3D)imaging provides incremental diagnostic information by allowingvisualisation of structures in multiple planes. We present threecases which demonstrate how 3D imaging provides better mor-phological assessment of valve leaflets and associated structures,allows greater accuracy in identifying complications of IE such asleaflet perforation or abscess as well as improving assessment ofvegetation size and morphology.

A 27 year old male presented with pyrexia, lethargy and weightloss. A transesophageal echocardiogram (TEE) (Fig. 1, Panel A)demonstrates thickened aortic annulus with echo lucent areas sug-gestive of an aortic root abscess (dashed arrow). A possible vegeta-tion is seen attached to mid-anterior mitral valve leaflet (arrow)and a further vegetation is attached to the base of the aortic valvecusp. 3D TEE (Fig. 1, Panel B) clarifies the situation. A long, mobilevegetation is attached to the non-coronary cusp (arrow). An

Echocardiography Laboratory,

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abscess cavity (Fig. 1, Panel C) is clearly identified extending from

In a second case, a 64 year old male with previous bio-prostheticaortic valve replacement for endocarditis admitted with syncope.Blood cultures grew Streptococcus bovis. 2D TEE demonstrated alarge vegetation attached to aortic valve although it is difficult toidentify its exact attachments (Fig. 2, Panel C). 3D TEE clearly de-marcates the long (1.5 cm × 0.7 cm), irregularly shaped, mobilevegetation and demonstrates it is attached to non-coronary cusp(Fig. 2, Panel D). The highly mobile vegetation intermittentlyprolapses into the left ventricular outflow tract causing partial ob-struction (Fig. 2, Panel E).

A 44 year old female who previously underwent an aortic root re-placement and implantation of Freestyle aortic bio-prosthesis for bicus-pid aortic valve and dissection presented with fever and lethargy. 2DTEE demonstrated a large, mobile vegetation (1.5 × 0.7 cm) attachedto non-coronary cusp (arrow) together with multiple other vegetations(dashed arrow) (Fig. 3, Panel A). Colour Doppler showed a regurgitantjet although the exact aetiology was unclear (Fig. 3, Panel B). 3D zoomdemonstrates large perforation of left coronary cusp of aortic valve(arrow) as well as vegetation on the non-coronary cusp (dashedarrow) (Fig. 3, Panel C).

Decision making in IE is complex. The most common indicationsfor early surgery are development of heart failure, uncontrolled in-fection or risk of embolism. Heart failure caused by valve destruc-tion occurs due to leaflet perforation, chordal rupture orinterference with leaflet closure. Uncontrolled infection is com-monly due to perivalvular abscess formation and the risk of embo-lism is related to vegetation size and mobility [1]. The three casesdemonstrate how traditional 2D TEE may provide incomplete ana-tomical information. 3D imaging improved identification and char-acterisation of the complications of IE. The complementary dataprovided aids in decision making with regard to both requirementsfor, timing and planning of surgery.

ent of complications of infective endocarditis by 3D transesophageal014.04.029

Fig. 1. Three Dimensional Transesophageal Echocardiography Characterises Complications of Infective Endocarditis..

Fig. 2. Pathological Correlations With Echocardiography..

e2 S. Bhattacharyya et al. / International Journal of Cardiology xxx (2014) xxx–xxx

Please cite this article as: Bhattacharyya S, et al, Comprehensive assessment of complications of infective endocarditis by 3D transesophagealechocardiography, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.04.029

Fig. 3. Incremental Diagnostic Value of Three Dimensional Echocardiography To Characterise Vegetations..

e3S. Bhattacharyya et al. / International Journal of Cardiology xxx (2014) xxx–xxx

References

[1] Habib G, Hoen B, Tornos P, et al. ESC Committee for practice guidelines. Guidelines onthe prevention, diagnosis, and treatment of infective endocarditis (new version2009): the task force on the prevention, diagnosis, and treatment of infective

Please cite this article as: Bhattacharyya S, et al, Comprehensive assessmechocardiography, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2

endocarditis of the European Society of Cardiology (ESC). Endorsed by theEuropean Society of Clinical Microbiology and Infectious Diseases (ESCMID) and theInternational Society of Chemotherapy (ISC) for Infection and Cancer. Eur Heart J2009;30:2369–413.

ent of complications of infective endocarditis by 3D transesophageal014.04.029