DK2985_C000 1..28 - AlSharqia Echo Club

520 Transesophageal Echocardiography(A)(B)VEGETATIONSLAAoLVRVLVOTFigure 23.34 A 60-year-old woman who presented with a pneumococcal meningitis. Mid-esophageal long-axis view revealed a vegetationon the aortic valve as well as a mass attached to the basal interventricular septum where the jet of aortic regurgitation is directed.The multilobulated appearance is suggestive of a vegetation (Ao, aorta; LA, left atrium; LV, left ventricle; LVOT, left ventricular outflowtract; RV, right ventricle).which coalescing echo-free spaces gradually evolve into anewly formed cavity (see Fig. 15.31). Once a pseudoaneurysmhas clearly formed, the presence of blood flowin and out of the cavity can be seen with color flowimaging. The examination of AoV endocarditis shouldthus warrant a careful evaluation of the periaortic areaand the posterior mitral annulus (Figs. 23.34 and 23.35).Tricuspid valve endocarditis is usually an acute ratherthan a subacute process. Staphylococcus aureus is themost common infecting organism, since predisposingfactors include intravenous drug abuse, infected cathetersand virulent skin infection. In contrast to left-sidedvalves, infective endocarditis among intravenous drugusers occurs on a structurally normal valve. Tricuspid vegetationsgenerally appear as large echodense masses whichdisrupt the usual smooth contour of the TV (see Figs.19.14 and 19.15). Vegetative growth may occur on theatrial surface, the leaflet margins, or the ventricularsurface. Significant leaflet destruction and rupture of thechordae tendinea are common (30).The pulmonic valve (PV) is the least commonlyinvolved in infective endocarditis. It usually occurs inpatients with congenital heart disease such as pulmonicstenosis (PS), patent ductus arteriosus, tetralogy of Fallotor ventricular septal defect (VSD). As mentioned previously,vegetations develop on areas of endothelialdamage by impinging flow jets. Thus, in patients withVSD, vegetations can appear at the site of the jet lesionon the endocardium of the RV.Vegetations on prosthetic valves are typically more difficultto detect than those involving native valves, as visualizationof their components and specific design oftenrequires specific angulations, complicated even more byacoustic shadowing from prosthetic material. The presenceof both mitral and aortic prostheses is particularly challenging,as the aortic prosthesis obscures the mitral valve intransthoracic imaging while the opposite occurs withtransesophageal imaging. The advent of multiplanetransesophageal transducers has been particularly helpfulin enabling observation from multiple viewing positions(A)(B)LALUPVLAA INFECTEDTHROMBUSLVFigure 23.35 Mid-esophageal views of a 60-year-old woman with pneumococcal meningitis and endocarditis. A repeat transesophagealechocardiographic exam (TEE) revealed a new mass in the left atrial appendage (LAA), not seen on the first TEE done seven days before.The multilobulated appearance of the mass, the absence of atrial fibrillation and the ongoing bacteremia suggested the presence of a newsource of infection. An infected thrombus was surgically removed (LA, left atrium; LUPV, left upper pulmonary vein; LV, left ventricle).