DK2985_C000 1..28 - AlSharqia Echo Club

Pulmonic and Tricuspid Valves 457(A)(B)TVSLVEGETATIONLARALVRVTVALFigure 19.14 Mid-esophageal four-chamber view of a patient with endocarditis of the tricuspid valve. An echogenic mobile mass isseen between the tricuspid valve septal leaflet (TVSL) and the anterior leaflet (TVAL) (LA, left atrium; LV, left ventricle; RA, rightatrium; RV, right ventricle).by bacteremia (25). The identification of vegetation onforeign material can be challenging with TTE, as cathetersoften produce reverberations (26,27). Transesophagealechocardiography offers the advantage of a higher resolutionto differentiate vegetation attachment to indwellingcatheters or wires vs attachment to valves (26). Vegetationson pacemaker wires typically appear as sleevelikewith satellite vegetations on the TV associated inmore than 2/3 of cases of pacemaker wire infections(26–29) (Fig. 19.15). Transesophageal echocardiographyalso offers the ability to visualize a greater catheterlength including the superior vena cava using the sagittal90–1208 bicaval view. Importantly, the site of pacemakeror defibrillator infection may be in the pulse generatorpocket, remote from the imaging capabilities of TEE andsometimes even missed by clinical examination (29).Thus, a negative TEE does not preclude the diagnosis ofcardiac device infection. In cases with a high level of suspicion,evaluation of the pacemaker generator pocket witha computed tomography (CT) scan can complement the(A)(B)VEGETATIONLARARVLVPACEMAKER WIRE(C)(D)IVCLARAAoVEGETATIONON PACEMAKER WIREFigure 19.15 Echogenic material attached to a pacemaker wire seen in a mid-esophageal four-chamber (A, B) and 908 view (C, D)(Ao, aorta; IVC, inferior vena cava; LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle).