Circulation. 2008;118:e1-e3
doi: 10.1161/CIRCULATIONAHA.107.727339
(Circulation. 2008;118:e1-e3.)
© 2008 American Heart Association, Inc.
Images in Cardiovascular Medicine |
Cardiac Magnetic Resonance Imaging Identifies the Elusive Perivalvular Abscess
Aaron L. Sverdlov, MBBS, FRACP;
Karen Taylor, MBBS;
Andrew G. Elkington, MD, MRCP;
Christopher J. Zeitz, MBBS, FRACP, PhD, FCSANZ;
John F. Beltrame, BSc, BMBS, FRACP, PhD, FCSANZ
From University of Adelaide, Department of Cardiology, The Queen Elizabeth Hospital, Woodville South, Australia.
Correspondence to J.F. Beltrame, PhD, Department of Cardiology, The Queen Elizabeth Hospital, 28 Woodville Rd, Woodville South, South Australia, 5011, Australia. E-mail john.beltrame{at}adelaide.edu.au
A 51-year-old man with known bicuspid aortic valve disease presented with a 3-day history of fever. Examination revealed mixed aortic valve disease (confirmed by transthoracic echocardiography) and microscopic hematuria. He was given intravenous antibiotics, and blood cultures confirmed Staphylococcus aureus infection.
The patient subsequently developed first-degree heart block (Figure 1) but both transthoracic echocardiography (Movie I) and transesophageal echocardiography (Movie II) did not identify the clinically suspected perivalvular abscess. His chest x-ray examination was unremarkable except for left ventricular dilatation (Figure 2). However, cardiovascular magnetic resonance (CMR) imaging demonstrated a structural abnormality in the basal septum with surrounding late enhancement after gadolinium administration, which is consistent with a septal abscess (Figure 3).
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Figure 1. Twelve-lead ECG shows first-degree heart block (PR interval,  270 ms). Arrows point to P waves.
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Figure 2. Chest x-ray images in posterior-anterior and lateral projections reveal left ventricular enlargement and small bilateral pleural effusions.
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Figure 3. CMR (4-chamber views) indicates an area of increased enhancement in the intra-atrial septum (arrow).
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Surgical debridement was initially deferred pending control of the active infection. When the patient later developed transient complete heart block (Figure 4), reassessment with transesophageal echocardiography still did not demonstrate a septal abscess; however, CMR showed clearly identifiable aortic perivalvular abscess (Figure 5 and Movie III). Similarly, CMR with delayed hyperenhancement in the short-axis plane showed an area of hyperenhancement (representing walls of the abscess) and a surrounding area of no signal (abscess cavity itself) (Figure 6). Successful abscess debridement and aortic valve replacement (Figure 7) were undertaken, and histology confirmed a noncoronary cusp abscess with acute inflammatory changes within both aortic valve leaflets (Figure 8).
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Figure 6. CMR (short-axis delayed hyperenhancement view through the ascending aorta) reveals an area of hyperenhancement (abscess wall) surrounding an area of no signal (perivalvular abscess itself, arrow).
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Figure 7. Intraoperative photograph of dissected abscess cavity; roof and floor of the abscess cavity are visible (arrow).
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Figure 8. Hematoxylin and eosin staining of the section through the valve and annulus reveals fibrosis and inflammatory cell infiltration (arrow).
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This is the first reported case of perivalvular abscess identification via CMR imaging. It reflects the clinical utility of this imaging modality with its high-quality spatial resolution. Echocardiography is the established imaging modality for the diagnosis of perivalvular abscess, with transesophageal echocardiography (80% sensitivity) being more sensitive than transthoracic echocardiography (38% sensitivity).1,2 In this case, however, echocardiographic examinations (including transesophageal echocardiography) failed to demonstrate the suspected abscess. In contrast, CMR confirmed the presence of the abscess in its early stages and provided useful images for the surgeon when debridement was undertaken. Hence, CMR warrants consideration in the clinical evaluation of suspected cardiac abscess.
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Acknowledgments
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We would like to thank the staff of the Radiology Department
at the Queen Elizabeth Hospital, Adelaide, Australia and the
staff of the Cardiothoracic Surgical Department at the Royal
Adelaide Hospital, Adelaide, Australia for their help with this
article. Dr Beltrame is a National Heart Foundation of Australia
Research Fellow.
Disclosures
None.
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Footnotes
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The online-only Data Supplement, which contains Movies I through III, can be found at http://circ.ahajournals.org/cgi/content/full/118/1/e1/DC1.
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References
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1. Daniel WG, Mügge A, Martin RP, Lindert O, Hausmann D, Nonnast-Daniel B, Laas J, Lichtlen PR. Improvement in the diagnosis of abscesses associated with endocarditis by transesophageal echocardiography.
N Engl J Med. 1991; 324: 795–800.
[Abstract]2. Choussat R, Thomas D, Isnard R, Michel PL, Iung B, Hanania G, Mathieu P, David M, du Roy de Chaumaray T, De Gevigney G, Le Breton H, Logeais Y, Pierre-Justin E, de Riberolles C, Morvan Y, Bischoff N. Perivalvular abscesses associated with endocarditis: clinical features and prognostic factors of overall survival in a series of 233 cases. Perivalvular Abscesses French Multicentre Study. Eur Heart J. 1999; 20: 232–241.[Abstract/Free Full Text]
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