Role of 3D transoesophageal echocardiography in the study of infective endocarditis. Demonstration in a case collection

Figures

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  Figure 1. Vegetations. (A) TOE at mid-oesophageal level acquired at 131°, volume rendering with transillumination. View in face of the closed mitral valve, showing three ovoid vegetations (red arrows) (Video 1). (B) MPR of the previous image, locating vegetations in A1, A2, and P3 (white arrows), with the central one being the longest at 6 mm in length. (C) TOE at mid-oesophageal level acquired at 134°, volume rendering with transillumination. Surgeon’s view of the mitral valve shows sessile vegetations along the intercommissural line (red arrows). (D) MPR of the previous case, showing moderate thickening of medial scallops (bottom left quadrant), with the presence of vegetation at the A2 level (white arrow). (E) TOE at mid-oesophageal level acquired at 121°, volume rendering of mitral bioprosthetic valve. Medial section of the prosthesis shows filamentous vegetation longitudinally traversing the prosthesis (white arrow). (F) MPR of the previous volume, displaying maximum lengths in different views (white arrows). LA, left atrium; LV, left ventricle.

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  Figure 2. Vegetations. (A) TOE at mid-oesophageal level acquired at 134°, volume rendering. Long-axis view of the native aortic valve shows three filamentous vegetations (white arrows). (B) MPR of the previous image, locating vegetations on three leaflets, with the non-coronary cusp-dependent one being the largest at 14 mm (bottom right quadrant). (C). Colour Doppler MPR of the same case, determining the area of major regurgitation jet at 0.4 cm2 in the short-axis view (top right quadrant). (D) TOE at mid-oesophageal level acquired at 120°, volume rendering. Section and superior view of the native aortic valve shows multiple vegetations (white arrows) distorting the valve. (E) MPR of the previous image locates vegetations on all three leaflets and identifies the largest vegetation of 28 mm embedded in the left coronary cusp. (F) TOE at mid-oesophageal level acquired at 45°, MPR of the native aortic valve, showing a small ovoid vegetation of 6 mm maximum diameter on the right coronary cusp. LA, left atrium; LV, left ventricle.

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  Figure 3. Vegetations. (A) TOE at mid-oesophageal level acquired at 74°, simultaneous biplane imaging. Pulmonary valve affected by two filamentous vegetations (white arrows), the largest being 14 mm in length. (B) Volume rendering of the pulmonary valve from the previous case, showing filamentous vegetations with enhanced realism. (C) TOE at mid-oesophageal level acquired at 88°, simultaneous biplane imaging. Right atrial focus. In the first view, a vegetation is seen near the inferior vena cava ostium and part of the central venous catheter trajectory (white arrow). In the second image, a pedunculated vegetation of 13 mm in diameter is visible (Video 2). (D) Volume rendering with transillumination of the same patient, showing vegetation with digitiform morphology (red arrow). (E) TOE at mid-oesophageal level acquired at 35°, simultaneous biplane imaging. Pulmonary artery trunk focus. Multiple clustered vegetations are shown in the pulmonary artery trunk (long white arrows). Additionally, numerous vegetations are implanted at the level of the pulmonary valve (short white arrows). (F) TOE at mid-oesophageal level acquired at 93°, simultaneous biplane imaging. Interatrial septum focus. A…

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  Figure 4. Abscess and fistula. (A) TOE at mid-oesophageal level acquired at 92°, volume rendering with transillumination. Mitral valve with a large central image compromising the lateral and medial leaflets, corresponding to a mitral abscess. (B) TOE at mid-oesophageal level acquired at 105°, MPR of the mitral valve showing an abscess of the mitral annulus adjacent to P1–P2 (white arrows) (Video 3). (C) TOE at mid-oesophageal level acquired at 100°, volume rendering. Tricuspid valve focus, showing large abscesses in the septal and anterior leaflets, fused in systole (white arrow). (D) TOE at mid-oesophageal level acquired at 45°, volume rendering. Aortic prosthesis focus, revealing a giant abscess arising from the aortic position (red star) and extending with vegetations to the right cavities and left atrium (white arrows). (E) TOE at mid-oesophageal level acquired at 47°, 2D with colour Doppler, image from the same study. Biological aortic prosthesis focus, showing a fistulous tract (red arrow) from the aortic pseudoaneurysm abscess (red star) to the right atrium (Video 4). (F) TOE at mid-oesophageal level acquired at 47°, volume rendering, continuation of the previous image. Aortic…

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  Figure 5. Pseudoaneurysm. (A) TOE at mid-oesophageal level acquired at 78°, volume rendering. Biological aortic prosthesis with evidence of pseudoaneurysm of the mitroaortic fibrosa (white arrow) communicating with the left ventricular outflow tract. Additionally, multiple vegetations are visible inside it (thin white arrows). (B) MPR of the previous case, showing the pseudoaneurysm in short and long axes, and thickening of the containing wall, corresponding to an abscess (white star). (C). Volume rendering with colour Doppler of the same patient. Non-simultaneous biplanar images show flow passage from the aorta to the cavity (white arrow, left image) and from the cavity to the left ventricular outflow tract (white arrow, right image). (D) TOE at mid-oesophageal level acquired at 141°, volume rendering. Biological aortic prosthesis focus, showing pseudoaneurysm of the mitroaortic fibrosa (white arrow) connected to the left ventricular outflow tract. It is important to note the thickening of the leaflets. (E) TOE at mid-oesophageal level acquired at 50°, volume rendering. Biological aortic prosthesis focus, showing pseudoaneurysm of the mitroaortic fibrosa with thickened lining, and…

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  Figure 6. Perforations. (A) TOE at mid-oesophageal level acquired at 105°, volume rendering with transillumination. Oblique atrial view of the mitral valve. A perforated aneurysm is observed in the posterior mitral leaflet (Video 6). (B) MPR of the same case, showing the perforated aneurysm located in P2 in multiple views. (C) TOE at mid-oesophageal level acquired at 45°, volume rendering. Native aortic valve with multiple small vegetations (small white arrows) and two perforations in the non-coronary and right leaflets (red arrows). Note the presence of a subaortic membrane (large white arrow). (D) MPR with colour Doppler of the previous study, showing multiple perforations (small white arrows) causing severe aortic insufficiency. Regurgitant jet with restricted trajectory due to subaortic membrane (large white arrow). (E) TOE at mid-oesophageal level acquired at 143°, simultaneous biplanar image. Biological aortic prosthesis with evidence of multiple fenestrations in its leaflets (white arrows). (F) Biplanar image with colour Doppler of the previous image, highlighting multiple non-eccentric regurgitant jets (white arrows) almost completely occupying the left ventricular outflow tract…

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  Figure 7. Aneurysm and dehiscence. (A) TOE at mid-oesophageal level acquired at 30°, volume rendering with transillumination. Mitral valve in a face view showing an aneurysm involving A1–2, along with two small medial vegetations (white arrows). (B) MPR of the previous study showing the profile of the aneurysm in multiple views, as well as its location between the boundary of A1–2. Also, vegetations are localized in A2 (white arrow) (Video 8). (C) Volume rendering of the same case. Longitudinal section of the mitral aneurysm. (D) MPR with colour Doppler of the same patient, displaying the integrity of this cavity in multiple planar views. (E) TOE at mid-oesophageal level acquired at 59°, volume rendering. Biological mitral prosthesis in a face view, showing suture dehiscence at the postero-medial level (white arrow) (Video 9). (F) Volume rendering of the previous case, highlighting a central regurgitant jet (small white arrow) and a larger postero-medial eccentric jet exceeding 25% of the annular circumference (large arrow). LA, left atrium; LV, left ventricle.