More Than a Simple Vegetation: The Trifecta of Mitral Valve Leaflet Perforation, Windsock Aneurysm, and Mitral Valve Abscess

Figures

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  Figure 1. (A) Initial transesophageal echocardiographic midesophageal biplane views at 0° and 90° demonstrated a large vegetation involving the posterior MV leaflet extending into the posterior mitral annulus (arrow). (B, C) Three-dimensional TEE (left atrial view) demonstrated a large vegetation on the posterior MV leaflet involving the posterior annulus (white arrow).

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  Figure 2. (A) TEE after second presentation: midesophageal biplane views at 140° and 50° (inverted right-left) subsequently demonstrated a windsock aneurysm arising from the posterior leaflet with systolic expansion (A; arrow) and diastolic collapse (B).

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  Figure 3. (A) Transesophageal echocardiographic midesophageal long-axis view at 140° showing a prominent perforation in the posterior MV leaflet on 2D imaging (white arrow). (B) Transesophageal echocardiographic midesophageal long-axis view at 140° demonstrating severe MR resulting from the perforation on color Doppler imaging (black arrow).

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  Figure 4. (A, B) Three-dimensional TEE (left atrial view) demonstrated a windsock aneurysm arising from the posterior MV leaflet with associated leaflet perforation (arrow). (C) Three-dimensional TEE (left atrial view) with color suppression showing a focal perforation (white arrow) at the central aspect of the posterior MV leaflet (P2). (D) Three-dimensional color TEE demonstrated severe MR due to perforation (black arrow).

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  Figure 5. Three-dimensional TEE with multiplanar reconstruction (MPR) showing annular involvement on cross-sectional plane (white arrow). Three-dimensional MPR was able to clearly demonstrate extension into the posterior annulus indicative of perivalvular involvement. Ao, Aorta; LA, left atrium.

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  Figure 6. (A) TEE of the mechanical AV: midesophageal biplane views at 140° and 50° demonstrating suspicious thickening of the prosthetic leaflets (arrow). (B) Three-dimensional TEE of the prosthetic AV (aortic view) also suggestive of leaflet thickening (arrow).

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  Figure 7. Intraoperative findings showing a large P2/P3 leaflet vegetation (yellow arrow), perforation (white arrow), and abscess formation (dotted line area) eroding into the posterior mitral annulus. The patient's prior saphenous vein graft (SVG; asterisk) to the posterior descending artery (PDA) was preserved.