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.
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 cm2, 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. 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.