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.