Unusual mitral annular vegetation diagnosed by transesophageal echocardiography

Lethal hemopericardium caused by infection of mitral annular calcification: An autopsy case report

Mitral annular calcification (MAC) is a chronic and degenerative condition involving calcification of the mitral annulus. MAC is a risk factor for coronary artery disease, cardiovascular events, stroke, and cardiovascular death. However, patients with MAC are often asymptomatic. Herein, we present the first case of cardiac tamponade due to infection of MAC in forensic pathology. An 80-year-old woman was found in cardiopulmonary arrest shortly after experiencing fatigue. She was transferred to a hospital, and despite chest compression and ventilation, she was pronounced dead due to no response. Postmortem computed tomography, autopsy, and histological examination showed MAC, abscess formation involving Gram-positive cocci on the MAC, and fistulation of the abscess into the intracardial pericardial cavities, resulting in a massive lethal hemopericardium.

Has transesophageal echocardiography changed the approach to patients with suspected or known infective endocarditis?

Infective endocarditis is still a great clinical challenge. Its diagnosis is difficult to establish, and mortality has remained around 30%. Early diagnosis and optimal treatment are crucial fo prognosis improvement. Echocardiography plays an indispensable role in the management of this disease, especially with the recently introduced approach, transesophageal echocardiography (TEE). TEE can overcome the limitations of transthoracic echocardiography (TTE) and is superior to TTE in almost every way in providing earlier and more information for the diagnosis and treatment of infective endocarditis. TEE detects valve vegetations with much higher sensitivity and specificity than TTE. It can demonstrate smaller vegetations in the early stage of the disease and vegetations on atypical locations (e.g., mitral valve annulus), and provides detailed characterization of vegetations (e.g., location, size, mobility, and changes during treatment). Such information is of great prognostic value and may help in selecting proper treatment. TEE is more sensitive for detecting complications, such as mitral valve perforation, abscess, and subaortic complications, which respond poorly to medicine and for which timely surgery may be the best treatment. For those with prosthetic valve endocarditis, TEE is especially useful because TTE is greatly limited by the acoustic shadow of prostheses. Both positive and negative results of TEE examination are valuable for confirming or excluding infective endocarditis. TEE also plays a unique role in intraoperative monitoring and can assess surgical results before the chest is closed. TEE has become an invaluable tool for the diagnosis and management of patients with suspected or known infective endocarditis.

Transesophageal echocardiography as a tool in the evaluation of patients with embolic disorders

TEE has become one of the most powerful tools for evaluating patients with unexplained stroke, TIA, and peripheral and pulmonary embolization. This is especially encouraging in view of the previously disappointing results of TTE in these patients. In addition to the dramatic results in terms of clot visualization and the other intracardiac sources of embolization described previously, a new extracardiac source has been identified, namely protruding atheromas in the thoracic aorta. These atheromas have been seen for the first time because of the new diagnostic window that has been opened by the development of TEE. Their recognition and follow-up may lead to information that will change the approach to a significant number of patients with embolic ischemic episodes.

Left ventricular outflow tract obstruction following repair of pneumococcal mitral annular abscess

An unusual case of a mitral annular abscess caused by Streptococcus pneumoniae was diagnosed by transesophageal echocardiography. The patient underwent surgical resection of the abscess and developed outflow tract obstruction. This is an unusual complication of the surgical procedure. The outflow tract obstruction may have been due to anterior displacement of the mitral valve by the abscess.

Mitral and tricuspid annular endocarditis. Diagnosis by transesophageal echocardiography

Two cases of infective endocarditis with vegetations attached to the mitral and tricuspid annuli are described. In both cases, the vegetations could not be identified by transthoracic echocardiography. These cases illustrate the advantage of TEE over the transthoracic approach in recognizing vegetations in extravalvular locations.