European Journal of Echocardiography Advance Access originally published online on May 13, 2008
European Journal of Echocardiography 2008 9(5):709-711; doi:10.1093/ejechocard/jen162
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2008. For permissions please email: journals.permissions@oxfordjournals.org
Aortic regurgitation and unusual diastolic mitral regurgitation
Marek Konka*,
Beata Kusmierczyk-Droszcz,
Olgierd Wozniak and
Piotr Hoffman
Department of Congenital Heart Disease, Institute of Cardiology, Alpejska 42, Warsaw 04-628, Poland
Received 17 January 2008; accepted after revision 13 April 2008; online publish-ahead-of-print 13 May 2008.
* Corresponding author. Tel: +48 (22) 3434457. E-mail address: mkonka{at}ikard.pl
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Abstract
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In patients with infective endocarditis affecting the aortic
valve, a secondary involvement of subaortic structures may occur
in a mechanism of direct extension or as a result of an infected
jet of aortic regurgitation striking the ventricular surfaces
of the mitral-aortic intervalvular fibrosa and the anterior
mitral leaflet (AML). We present a 29-year-old male with infective
endocarditis of the bicuspid aortic valve, who developed a secondary
infection of the subaortic tissues complicated by a perforation
of the AML. Echocardiographic examination revealed not only
systolic, but also diastolic mitral regurgitation.
Keywords: Endocarditis; Bicuspid aortic valve; Mitral valve leaflet perforation; Echocardiography
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Introduction
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Infective endocarditis affecting the aortic valve may lead to
secondary involvement of the mitral-aortic intervalvular fibrosa
and the anterior mitral leaflet (AML). Aortic lesions may extend
along the continuity of the mitral-aortic structures. Yet, the
secondary damage to the AML is caused more often by the infected
jet of aortic regurgitation hitting the ventricular surface
of the leaflet, or by the pronounced bacterial vegetation prolapsing
from the aortic valve into the left ventricular outflow tract.
The latter, known as the ‘kissing lesion’, is observed
in 10–15% of patients with infective endocarditis of the
aortic valve.
1,2 In this case report, we describe a patient
with infective endocarditis of the bicuspid aortic valve (BAV),
who developed a severe mitral regurgitation (MR) due to the
secondary involvement of the subaortic structures and a perforation
of the AML. Additionally to systolic MR, a diastolic wave of
retrograde blood flow was recorded through the perforation [from
the left ventricle (LV) to the left atrium]. The mechanism of
this diastolic MR was very unusual. In the echocardiographic
examination, it was identified as a part of aortic regurgitant
jet.
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Case description
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A 29-year-old man with the history of alcohol and drugs addiction,
chronic viral hepatitis (type B and C), and mild BAV regurgitation
was admitted to hospital with severe staphylococcal infection.
The patient presented with purulent cerebrospinal meningitis,
multiple brain and spleen abscesses, and ulnar artery mycotic
aneurysm. Transthoracic echocardiography (TTE) performed in
a local hospital revealed thickened margins of the BAV, progression
of aortic regurgitation (from mild to moderate), a minor jet
of central MR, and an additional
1.5 cm long structure on the
ventricular surface of the AML. After the initial success of
the antibiotic therapy, a fever relapsed together with the signs
of abrupt haemodynamic deterioration and the patient was immediately
transferred to our institute for further evaluation and treatment.
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TTE findings
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Transthoracic echocardiography confirmed thickened margins of
BAV (
Figure 1). Diastolic jet of aortic regurgitation was
directed towards the middle part of A2 segment of the AML, where
it was further divided into two parts. One of them propagated
along the surface of the AML, whereas the other was entering
the left atrium through the large perforation located exactly
at the place where the jet of aortic regurgitation was striking
(
Figure 2). Mitral retrograde flow (from the LV to the
left atrium) was recorded during both systole and diastole.
All time-dependant phenomena were assessed with the use of colour-coded
M-mode and continuous wave Doppler (
Figure 3).
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Figure 1 Transthoracic echocardiography. Short axis basal view (A) reveals the morphology of the bicuspid aortic valve (arrow). Parasternal long axis view (B) shows minor thickening of the margins of the aortic valve leaflets with small vegetations (arrow) and obvious perforation of the anterior mitral leaflet (double arrow). RA, right atrium; LA, left atrium; RVOT, right ventricle outflow tract; RV, right ventricle; LV, left ventricle; Ao, aorta.
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Figure 2 Doppler echocardiography with colour flow mapping. Transthoracic apical four-chamber view (A) reveals a perforation of the anterior mitral leaflet and massive retrograde wave directed into the left atrium. Apical long axis view (B) shows the jet of aortic regurgitation (single arrow) and its division into ‘ventricular’ and ‘atrial’ components (double arrows).
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Figure 3 Doppler echocardiography. Continuous wave Doppler (A) and colour-coded M-mode (B) show retrograde flow through the AML perforation into the left atrium during systole (long arrows) and diastole (short arrows), the latter being actually a part of aortic regurgitant jet.
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Transoesophageal echocardiography findings
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Transoesophageal echocardiography (TEE) was applied to assess
aortic valve more precisely. The margins of the aortic leaflets
were smooth, with no features of bacterial vegetation (
Figure 4A).
Transoesophageal echocardiography confirmed a large perforation
of the AML. Haemodynamically significant jets of regurgitation
were visualized with colour flow mapping (
Figure 4B and
C).
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Figure 4 Transoesophageal echocardiography; mid-oesophageal view at 142°. (A) Dilated cavity of the left ventricle, slightly thickened margins of the aortic valve leaflets and the anterior mitral leaflet perforation (arrow) without any evidence of vegetation. (B) Massive retrograde flow through the perforation of the anterior mitral leaflet (arrows). (C) A part of aortic regurgitant jet (single arrow) flows through the perforation into the left atrium creating ‘diastolic mitral regurgitation’ (arrows).
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Discussion
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The patient described was diagnosed with BAV as a child, but
his aortic regurgitation was mild and did not require a surgical
repair. In the setting of chronic viral hepatitis and alcohol
and drugs abuse, he developed infected endocarditis of BAV,
complicated by peripheral embolism. Initial echocardiograms
revealed minor inflammatory lesions in BAV and a large bacterial
vegetation (
1.5 cm) on the ventricular surface of the AML. Infective
endocarditis of the aortic valve may proliferate onto the adjacent
structures.
3 Lesions of the mitral valve that are secondary
to the aortic infective process are known as ‘mitral kissing
vegetations’. This type of lesion develops on morphologically
and functionally normal leaflet, when the aortic valve vegetation
or aortic retrograde flow has a direct contact with the ventricular
surface of the AML.
2,3 In the presented case, we were given
only a description of lesions which might have been labelled
as ‘mitral kissing vegetations’ and clinically resulted
in extensive peripheral embolism. Rapid deterioration of general
condition was caused by acute severe MR with prominent impact
of aortic backward flow via the AML perforation. This should
be regarded, in terms of haemodynamics, as diastolic MR. Its
mechanism was very unusual, because high-velocity diastolic
MR was generated directly by backward aortic flow to the left
atrium, whereas diastolic MR more often is caused only by high
end-diastolic LV pressure.
4 Transoesophageal echocardiography,
generally believed to be superior to TTE in the assessment of
lesions and complications inflicted by infective endocarditis,
confirmed all transthoracic findings and excluded vegetations
on the mitral or aortic leaflets and helped to decide about
the extent of surgical intervention. Aortic valve was replaced
by an artificial prosthesis, and the AML perforation was repaired
with a pericardium patch.
Conflict of interest: none declared.
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References
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- Oakley C. The mitral kissing vegetation. Eur Heart J (2002) 23:11.[Free Full Text]
- Piper C, Hetzer R, Korfer R, Bergemann R, Horstkotte D. The importance of secondary mitral valve involvement in primary aortic valve endocarditis. The mitral kissing vegetation. Eur Heart J (2002) 23:79–86.[Abstract/Free Full Text]
- Karalis DG, Bansal RC, Hauck AJ, Ross JJ Jr, Applegate PM, Jutzy KR, et al. Transesophageal echocardiographic recognition of subaortic complications in aortc valve endocarditis. Circulation (1992) 86:353–62.[Abstract/Free Full Text]
- Berger RL, Katz E, Tunick P, Kronzon I, et al. The ‘A-dip’ of diastolic mitral regurgitation: an unusual Doppler flow pattern in a patient with severe aortic insufficiency and complete heart block. Eur J Echocardiogr (2008) 9:69–71.[Abstract/Free Full Text]
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Abstract
Introduction