To the Editor,
The introduction of real time three-dimensional (RT3D) echocardiography has significantly improved the visualization of cardiac structures, particularly the mitral valve.1 Several publications have shown that RT3D echocardiography provides additional information when assessing endocarditis in prosthetic valves,2 and that RT3D transesophageal echocardiography (TEE) is superior to two-dimensional TEE (2DTEE) imaging in detecting vegetations and added complications.3
We report our experience of using RT3DTEE to diagnose complex mitral regurgitation (MR) in several patients from a series who underwent mitral valve repair after endocarditis.
We present the case of a 66-year-old patient who was admitted because of prolonged fever and positive blood cultures for Streptococcus faecalis.
The transthoracic echocardiogram showed a dilated left ventricle (LV) with a diastolic diameter of 58 mm, 58% ejection fraction, and inferobasal akinesia. The ECG showed a pattern of evolved silent inferior myocardial infarction.
The 2DTEE (Figure 1A, Video 1) shows a restriction of posterior mitral valve leaflet mobility (PMV) and the presence of vegetation on the atrial side of anterior mitral valve leaflet (AMV). The bicommissural plane (Figure 1B) showed a regurgitant jet at the level of the posterior commissure and a second jet (arrow) in the lateral aspect of the left atrium (LA), secondary to the functional ischemic restriction of PMV.
Figure 1. A, two-dimensional transesophageal echocardiography, 0°. B, two-dimensional transesophageal echocardiography, bicommissural plane 70°, Doppler color. C, three-dimensional transesophageal echocardiography of the mitral valve, ventricular perspective. D, three-dimensional transesophageal echocardiography of the mitral valve, atrial perspective.
The ventricular perspective of the mitral valve in RT3DTEE (Figure 1C) showed leaflet coaptation was lacking (arrow) and less echogenicity at the level of the posterior commissure. This was confirmed by the view from the atrial side, showing a broad prolapse of the A3-P3 scallops and multiple vegetations (arrow) at the level of the middle and posterior scallops of both leaflets (Figure 1D).
Coronary angiography showed chronic occlusion of the posterolateral branch of the right coronary artery.
Surgery confirmed the RT3DTEE findings and an edge-to-edge suture of the A3-P3 was performed, together with a resection of vegetations and the implant of a rigid, no. 28 ring. MR was not detected on intraoperative TEE and mitral area after repair was 1.7 cm2.
A second patient, aged 26 years, was referred from another hospital for mitral repair surgery. The patient had been diagnosed 6 months earlier with AMV perforation secondary to endocarditis from Streptococcus mitis. In the bicommisural plane, 2DTEE (Figure 2A) showed a regurgitant jet located at the posterior commissure. From the atrial perspective (Figure 2B), RT3DTEE showed a mitral recess (cleft) between the A2 and A3 scallops and the presence of broken ruptured chordae at the level of the posterior commissure (arrow).
Figure 2. A, two-dimensional transesophageal echocardiography, bicommissural plane 60°, Doppler color. B, three-dimensional transesophageal echocardiography of the mitral valve, atrial perspective. C, two-dimensional transesophageal echocardiography, 0°. D, three-dimensional transesophageal echocardiography of the mitral valve, atrial perspective.
These findings were confirmed during surgery. The cleft was sutured and annuloplasty with a no. 30 rigid ring performed. There was no residual MR.
The third patient we present was aged 60 years and had a history of multiple myeloma and a venous reservoir. Two months previously, she had developed Staphylococcus aureus bacteremia secondary to infection of the reservoir.
She was referred from another center with a diagnosis of posterior mitral annular abscess with fistulization to LA and LV.
The 2DTEE (Figure 2C) showed a cavity located laterally to the posterior mitral valve leaflet and corresponding to a pseudoaneurysm with rupture at LA and PMV perforation (arrows). From the atrial perspective, the RT3DTEE (Figure 2D, Video 2) showed a hole in the base of the PMV at the level of the P2 scallop (arrow), the presence of ruptured chordae (arrows) in the A2-P2 binding, and a prolapse of the latter scallop. Color Doppler revealed perforation of the pseudoaneurysm in LA and a second eccentric anteriorly directed jet related to the prolapsed PMV (Video 3).
During surgery, the pseudoaneurismatic cavity was obliterated and communication with LA and the PMV perforation were closed. A prolapse of the P2-3 union and ruptured chordae in A2 were confirmed. Two neochordae were implanted, edge-to-edge anastomosis was performed in the posterior commisure, and a complete rigid no. 30 ring was placed, with good results on intraoperative TEE.
Estimates of the incidence of endocarditis in the general population range from 16 to 62 cases per million people per year. Although mitral valve replacement has been proposed for many years as the treatment for mitral endocarditis, mitral valve repair has become increasingly popular, and a recent review confirmed that it leads to good results in patients with endocarditis.4
Cases of large, complex mitral endocarditis occasionally present and require a thorough knowledge of the anatomy, mechanisms, and severity of valvular regurgitation.
Our initial experience with RT3DTEE shows it to be particularly useful in patients with complex MR and multiple mechanisms. We found that it improves on the findings obtained with 2DTEE and that it provides the surgeon with information of great importance for appropriate valve repair.
Appendix A. Supplementary materialSupplementary material associated with this article can be found in the online version, available at doi:10.1016/j.rec.2011.04.018.
Appendix A. Supplementary dataCorresponding author: fjlopezp@telefonica.net