Four Faces of Infective Endocarditis: Where Thinking Outside the Box Was Crucial

Figures

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  Figure 1. Apical 4-chamber view of the transthoracic echocardiography of case 1 with infected CIED in the right atrium with a large vegetation on the atrial site. (A): on admission, the size of the vegetation is 25 × 17 mm. (B): the vegetation 42 days after antibiotic IV and anticoagulation has reduced size to below 20 mm—this allowed the CIED to be safely extracted percutaneously. RV: right ventricle; LV: left ventricle; RA: right atrium; LA: left atrium.

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  Figure 2. Transthoracic echocardiography of the right-sided IE of non-compliant high-risk young PWID with relapsing IE. (A): A4CV showing TV vegetation. (B): Modified parasternal long-axis view showing RV inflow and TV vegetation. (C): Modified parasternal long-axis view showing RV inflow and TV vegetation, after readmission post self-discharge. (D): Colour Doppler image of modified parasternal long-axis view showing RV inflow—Tricuspid Regurgitation (TR) after readmission. RV: right ventricle; LV: left ventricle; RA: right atrium; LA: left atrium.

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  Figure 3. Apical 4-chamber view of transthoracic echocardiography of degenerated biological Mitral Valve (bMV), (white arrow). (A): A4CV showing calcified stenotic bMV. (B): Colour Doppler flow in diastole across degenerated bMV. RV: right ventricle; LV: left ventricle; RA: right atrium; LA: left atrium.

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  Figure 4. Transoesophageal echocardiography image—cross-sectional image of degenerated immobile mitral valve bioprosthesis (bMV) (yellow arrows indicate vegetation attached to mitral valve). LV: left ventricle; LA: left atrium.

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  Figure 5. Transoesophageal echocardiography image of degenerated mitral valve bioprosthesis. (A): CW Doppler across stenotic mitral valve with mean gradient of 12 mmHg, (B): 3D planimetry mitral valve area (MVA); value of 0.77 cm2 in keeping with severe MS.

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  Figure 6. Transthoracic echocardiography colour Doppler and CW velocity after transcutaneous MViV intervention. (A): Colour Doppler flow of apical 4-chamber view of transthoracic echocardiography after percutaneous mitral valve-in-valve implantation (MViV). (B): Continuous Doppler velocity across MViV showing no significant inflow gradient. RV: right ventricle; LV: left ventricle; RA: right atrium; LA: left atrium.

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  Figure 7. FDG-PET CT after MViV implantation and relapsing enterococcus faecalis bacteraemia. FDG-PET-CT images of chest show focal tracer accumulation over MVR (yellow arrows), which is also present on non-attenuation correction images, suggestive of underlying infective endocarditis. Cardiac pacemaker leads, and generator showed no tracer accumulation. (A): coronal and (B) sagittal PET CT images of chest.

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  Figure 8. Series of transthoracic echocardiographies in valve clinic—CW measurements of transvalvular gradient across AV bioprosthesis since its implantation. Mean transvalvular gradient showed progressive increase suggestive of severe degenerative AS.

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  Figure 9. A three-dimensional rendering of CT aorta to show (A,B) the saccular pseudoaneurysm of the ascending aorta and dilated sinus of Valsalva (preoperatively, yellow arrows); (C) the replaced ascending aorta and proximal arch (post-operatively blue arrows).

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  Figure 10. CT images of mechanical AV replacement and TV annuloplasty ring. (A): mechanical aortic valve in diastole. (B): mechanical aortic valve in systole. (C): TV annuloplasty ring.

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  Figure 11. Transthoracic echocardiography—CW measurements of the transvalvular gradient across the mechanical AVR. After redoing the mechanical AVR and ascending Aorta replacement, the flow velocity across the mechanical AVR was normal.