Circulation, Vol 86, 353-362, Copyright © 1992 by American Heart Association
DG Karalis, RC Bansal, AJ Hauck, JJ Ross Jr, PM Applegate, KR Jutzy, GS Mintz and K Chandrasekaran
BACKGROUND. Secondary involvement of the mitral-aortic intervalvular
fibrosa and the anterior mitral leaflet (subaortic structures) can occur in
patients with aortic valve endocarditis. The secondary involvement of these
structures occurs as a result of direct extension of the infection from the
aortic valve or as a result of an infected aortic regurgitant jet striking
the ventricular surfaces of the mitral- aortic intervalvular fibrosa and
the anterior mitral leaflet. The abscess of mitral-aortic intervalvular
fibrosa can expand to form an aneurysm. Subsequently, this mitral-aortic
intervalvular fibrosa aneurysm can develop a perforation and communicate
with the left atrium, resulting in the systolic regurgitation of blood from
the left ventricular outflow tract into the left atrium. Secondary
infection can also occur on the ventricular surface of the anterior mitral
leaflet and result in the formation of an aneurysm or perforation of
anterior mitral leaflet. METHODS AND RESULTS. This study examines the
utility of transesophageal echocardiography in the detection of these
subaortic complications in 55 consecutive patients with aortic valve
endocarditis. A total of 24 patients (44%) had involvement of subaortic
structures, including four with an abscess in the mitral-aortic
intervalvular fibrosa, four with mitral-aortic intervalvular fibrosa
aneurysm, seven with perforation of the mitral-aortic intervalvular fibrosa
with communication into the left atrium, two with an aneurysm of the
anterior mitral leaflet, and seven with perforation of the anterior mitral
leaflet. The transesophageal echocardiographic findings were confirmed at
surgery in 20 patients and at necropsy in two. By comparison, transthoracic
echocardiography visualized these lesions in five of 24 patients (21%),
including none of four with mitral-aortic intervalvular fibrosa abscesses,
two of four with mitral-aortic intervalvular fibrosa aneurysms, one of
seven with mitral-aortic intervalvular fibrosa perforations, one of two
with anterior mitral leaflet aneurysms, and one of seven anterior mitral
leaflet perforations. Eccentric mitral regurgitation-type systolic jets
were noted in eight additional patients by transthoracic color flow
imaging, and this finding suggested the possibility of these unusual
subaortic complications. If these patients are included, then transthoracic
echocardiography suggested the presence of these subaortic complications in
13 of 24 patients (54%). CONCLUSIONS. The results indicate that 1)
involvement of the subaortic structures in patients with aortic valve
endocarditis may be more common than previously recognized, 2) patients
with aortic valve endocarditis and eccentric jets of mitral regurgitation
on transthoracic echocardiography should undergo further evaluation by
transesophageal echocardiography to exclude these unusual complications, 3)
precise recognition of these complications is of value in the optimal
medical and surgical management of these patients, and 4) these
complications may be responsible for unexplained congestive heart failure
and hemodynamic deterioration in some patients with aortic valve
endocarditis.
ARTICLES
Transesophageal echocardiographic recognition of subaortic complications in aortic valve endocarditis. Clinical and surgical implications
Department of Internal Medicine (Cardiology) Hahnemann University, Philadelphia, Pa.
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