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\begin{document}

\title{Transillumination: No one outwits me}



\author[1]{Javier Armenta-Moreno}%
\author[2]{Nilda Espinola-Zavaleta}%
\author[1]{Joaquin Berarducci}%
\affil[1]{Instituto Nacional de Cardiologia Ignacio Chavez}%
\affil[2]{Instituto Nacional de Cardiología }%


\vspace{-1em}



  
  \date{May 22, 2024}


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\selectlanguage{english}
\begin{abstract}
A 67-year-old woman with a history of mechanical valve replacement;
after the dental procedure, she developed dyspnea, malleolar edema, and
fever. The 2D transesophageal echocardiogram (TEE) showed no evidence of
valve obstruction, mild paravalvular leak, and no vegetations. In the 3D
TEE, the presence of masses suggestive of vegetations on the auricular
surface of the prosthesis was suspected which were more precisely
defined with transillumination rendering. This technique allowed us to
observe with precision the vegetations that were not visualized with
traditional methods. This highlights its usefulness in patients with
prosthetic valves where infective endocarditis is a serious
complication.%
\end{abstract}%



\sloppy


\textbf{Transillumination: No one outwits me}

Javier Ivan Armenta-Moreno\textsuperscript{1}, Joaquin
Berarducci\textsuperscript{1}*, Nilda
Espinola-Zavaleta\textsuperscript{1,2}

\textsuperscript{\textbf{1}} Nuclear Cardiology Department, National
Institute of Cardiology Ignacio Chavez,

Juan Badiano N\selectlanguage{ngerman}° 1, P.C 14080, Colonia seccion XVI, Tlalpan, Mexico City,
Mexico.

\textsuperscript{2} Department of Echocardiography, Centro Medico ABC,
I.A.P,

Calle Sur 136 N°117, P.C 01120, Colonia Las Americas, Alvaro Obregon,
Mexico City, Mexico.

\textbf{Short Title:} Prosthetic valve endocarditis

\textbf{*Correspondance:} Joaquin Berarducci

Nuclear Cardiology Department, National Institute of Cardiology Ignacio
Chavez,

Juan Badiano N° 1, P.C 14080, Colonia sección XVI, Tlalpan, Mexico City,
Mexico.

\textbf{Email:} jberarducci96@gmail.com

\textbf{Phone number:} +52 55 32 59 43 64

\textbf{FAX numbe} r: None

\textbf{Conflicts of interest:} None

\textbf{Funding:} None

\textbf{Acknowledgements:} None

\textbf{Abstract}

A 67-year-old woman with a history of mechanical valve replacement;
after dental procedure she developed dyspnea, malleolar edema and fever.
The 2D transesophageal echocardiogram (TEE) showed no evidence of valve
obstruction, mild paravalvular leak and no vegetations. In the 3D TEE,
the presence of masses suggestive of vegetations on the auricular
surface of the prosthesis was suspected which were more precisely
defined with transillumination rendering. This technique allowed us
observe with precision the vegetations that were not visualized with
traditional methods. This highlights its usefulness in patients with
prosthetic valve where infective endocarditis is a serious complication.

\textbf{Keywords:} Endocarditis, transesophageal echocardiogram,
transillumination, prosthetic valve.

A 67-year-old woman with a history of mechanical prosthesis due to
severe mitral regurgitation secondary to rheumatic heart disease at 16
years of age, with loss of follow-up. 50 years later, after dental
treatment, she began with dyspnea, malleolar edema and fever. The
physical examination includes pleural effusion, arrhythmic heart sounds,
hepatosplenomegaly, and anasarca. The 2D transesophageal echocardiogram
(TEE) showed a mitral prosthesis with a maximum gradient of 10 mmHg,
mean of 4 mmHg, valve area 3.3 cm\textsuperscript{2}, mild paravalvular
leak (Figure 1A,B,C: white arrow), moderate dilation of the right
cavities and severe tricuspid regurgitation (Figure 1D), PSAP 78 mmHg,
left ventricular function of 63\% and no presence of vegetations. In the
3D TEE, the presence of masses suggestive of vegetations on the
auricular surface of the prosthesis was suspected (Figure 2: green
arrows, Video 1), which were more precisely defined with
transillumination (Figure 3A, B, yellow and white arrows, Video 2), with
a diameter 1.91 x 0.57 cm. S. \emph{viridans} was isolated in the blood
culture, antimicrobial treatment was established with management for
acute heart failure. During surgery no vegetations were identified due
to the ten days antimicrobial therapy; transillumination technique was
essential to establish the final diagnosis. Biological mitral prosthetic
valve replacement, left atrial appendage closure and tricuspid ring
placement were performed, with excellent clinical evolution.

Transillumination is widely recommended due to a better anatomical and
functional definition, characterization and diagnosis of cardiac lesions
compared to traditional echocardiographic methods. This technique
allowed us to precisely diagnose the vegetations that were not
visualized with routinary echocardiographic methods; highlighting its
usefulness in patients with prosthetic valve endocarditis.

\textbf{Figure Legends}

\textbf{Figure 1.} 2D transesophageal echocardiography in four chamber
view with continuous wave and color flow. A: Prosthetic mitral valve
without vegetations in the atrial view and dilation of right cavities.
B: Paravalvular leak (white arrow). C: Prosthetic valve area 3.3
cm\textsuperscript{2} and mean gradient 4mmHg. D: Two jets of tricuspid
regurgitation (white arrows). Abbreviations: RA-right atrium; RV-right
ventricle; LA-left atrium.

\textbf{Figure 2.} 3D transesophageal echocardiography. A: Atrial view
of the mitral prosthetic valve in diastole (blue arrow pointing surgical
suture) B: Atrial view of the mitral prosthetic valve in systole. C, D:
Atrial view of the prosthetic mitral valve with evidence of a mass
(green arrow).

\textbf{Figure 3.} 3D transesophageal echocardiography with
transillumination. A: yellow arrows showing vegetations in the atrial
view of mitral prosthetic valve. B: Surgical view of mitral prosthetic
valve during systole with evidence of vegetations (white arrows). C:
Surgical view in end diastole presenting surgical suture (blue arrow)

\textbf{Video Legends}

\textbf{Video 1.} Surgical view of the mitral prosthetic valve without
evidence of vegetations.

\textbf{Video 2.} Surgical view of the mitral prosthetic valve with
transillumination showing two vegetations during systole.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-1/Figure-1}

\end{center}
\end{figure}\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/Figure-2/Figure-2}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
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\includegraphics[width=0.70\columnwidth]{figures/Figure-3/Figure-3}

\end{center}
\end{figure}

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