Eustachian Valve Endocarditis in an Elderly Woman

Actinomycotic endocarditis of the eustachian valve: a rare case and a review of the literature

Eustachian valve endocarditis caused by Actinomyces species is extremely rare. A literature review revealed only one reported case-caused by Actinomyces israelii in an intravenous drug abuser. Our patient, a 30-year-old woman who at first appeared to be in good health, presented with fever, a large mobile mass on the eustachian valve, and extensive intra-abdominal and pelvic masses that looked malignant. Histopathologic examination of tissue found in association with an intrauterine contraceptive device revealed filamentous, branching microorganisms consistent with Actinomyces turicensis. This patient was treated successfully with antibiotic agents. In addition to presenting a new case of a rare condition, we discuss cardiac actinomycotic infections in general and eustachian valve endocarditis in particular: its predisposing factors, clinical course, sequelae, and our approaches to its management.

Cor triatriatum dexter versus prominent Eustachian valve in an adult congenital heart disease patient

An eustachian valve (EV) remnant, if present, is usually noted by the presence of a thin ridge or a crescent-shaped fold of endocardium arising from the anterior rim of the inferior vena cava orifice due to the persistence of the right sinus venosus valve. Though the embryologic explanation of cor triatriatum dexter (CTD) is the same as that of the normal formation of the EV--lack of regression of the right sinus venosus valve--it is usually called CTD or divided right atrium when there are attachments on the atrial septum giving the appearance of a divided atrium. However, it's called prominent eustachian valve when the right sinus venosus valve has partly regressed, with no remaining septal attachments and without the appearance of a divided atrium. We present the case of an adult patient with an atrial septal defect with a high insertion of a giant EV, which mimics the echocardiographic appearance of divided right atrium.

Eustachian valve endocarditis: Rare case reports and review of literature

Eustachian valve endocarditis (EVE) is a distinctly rare and underdiagnosed entity. We report 2 new cases caused by vancomycin resistant Staphylococcus aureus and Staphylococcus hominis diagnosed on transesophageal echocardiography (TEE). Although, 63% of Eustachian valve endocarditis is caused by Staphylococcus aureus, we report the first case of vancomycin resistant Staphylococcus aureus and first case related to implantable venous access systems. EVE is now seen more commonly in elderly population with diverse microbial cultures and antibiotic sensitivities. TTE is the first modality for investigation of EVE, however a negative TTE does not preclude the diagnosis, as only 88% of cases were diagnosed on TEE.

Normal anatomic variants on transthoracic echocardiogram

Apart from their existence as medical curiosities, anatomic variants also double as diagnostic dilemmas. In the heart, more than in any other location in the body, misinterpretation of normal anatomic variants as pathologic entities can have a profound impact on treatment decisions and clinical consequences. Echocardiography is an easily accessible tool these days and is used routinely in most cardiac evaluations. Thus it becomes imperative for the echocardiographer to be cognizant of normal anatomic variants. Furthermore, echocardiographic findings should always be evaluated in their proper clinical context and diagnoses should never be entertained in a clinical vacuum. The literature is replete with numerous case reports and vignettes on these fascinating structures but is lacking in a formal review of normal anatomic variants. In this article, we have attempted a systemic review of normal variants, their embryologic origins, echocardiographic characteristics, and common pitfalls encountered in their evaluation.

Eustachian valve endocarditis: Is it worth searching for?

BACKGROUND

Only a few cases of eustachian valve endocarditis have been reported. Whether the eustachian valve is an uncommon site for a vegetation to be attached or whether the disease is missed because a systematic approach to this valve is not routinely performed in the search for vegetations is not known.

METHODS

Every patient suspected of having endocarditis undergoes a specific approach, which includes a systematic study of the eustachian valve. In 10 patients with large valves but without signs and symptoms of endocarditis, we identified 2 specific findings: width <3 mm and a regular oscillating movement. A blinded evaluation in the 10 control subjects and 30 patients with right-sided endocarditis, including the 5 with eustachian valve endocarditis, showed an agreement of 97% (39/40).

RESULTS

Five of 152 patients with right-sided endocarditis were found to have eustachian valve vegetations (3.3%). Patients were young (age range 22-34 years) and all had predisposing factors (3 intravenous drug abusers, 2 central venous lines), fever, and septic pulmonary embolism. Staphylococcus aureus was cultured in all cases. Tricuspid involvement was found in 4 patients, and only 1 patient had isolated eustachian valve endocarditis. All patients did well with culture-guided antibiotics.

CONCLUSIONS

Our results suggest that eustachian valve endocarditis may be more frequent than is believed. Thus a systematic interrogation of the eustachian valve should be included in the echocardiographic examination of a patient suspected of having endocarditis.