Infective Endocarditis of the Systemic Venous Baffle Following the Atrial Switch Procedure in an Adult

Figures

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  Figure 1. Transthoracic echocardiography, apical four-chamber view, showing the patient's unique anatomy of d-TGA following the atrial switch procedure. The morphologic right ventricle (RV) (systemic ventricle) is severely enlarged and hypertrophied, with bowing of the interventricular septum toward the morphologic left ventricle (LV) (subpulmonic ventricle). The pulmonary venous baffle (PVB) is well seen, whereas the more anterior systemic venous baffle (SVB) is not. There is no evidence of IE in this view.

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  Figure 2. TEE, midesophageal view at 30°, showing a four-chamber view equivalent to the transthoracic view seen in Figure 1. Right ventricular hypertrophy (RVH) is better appreciated on TEE, however. (A) No evidence of IE is initially seen. (B) After careful angulation toward the more anterior systemic venous baffle (SVB), a large echodensity concerning for IE is noted (arrow). LV, Left ventricle; PVB, pulmonary venous baffle; RV, right ventricle.

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  Figure 3. TEE, midesophageal view at 6°, with a zoomed-in view of the large echodensity concerning for IE (arrow). MV, Mitral valve; PVB, pulmonary venous baffle; SVB, systemic venous baffle; TV, tricuspid valve.

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  Figure 4. TEE, midesophageal view, with three-dimensional acquisition enabled showing the large echodensity concerning for IE (arrow). MV, Mitral valve; PVB, pulmonary venous baffle; SVB, systemic venous baffle.

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  Figure 5. TEE, midesophageal view at 0°, with a zoomed-in view of the large echodensity concerning for IE (arrow). The probe has been further advanced from the view in Figure 3 to see the echodensity in its entirety. Note that the echodensity appears to occlude the systemic venous baffle (SVB). MV, Mitral valve; PVB, pulmonary venous baffle; TV, tricuspid valve.

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  Figure 6. TEE, midesophageal view, with biplane imaging focused on the large echodensity concerning for IE (arrow). The four-chamber view (left) suggests that the echodensity may be occluding the systemic venous baffle (SVB), but the orthogonal view (right) shows that the echodensity (arrow) is eccentric in the SVB and primarily adherent to the posterior surface. PVB, Pulmonary venous baffle; TV, tricuspid valve.

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  Figure 7. TEE, midesophageal view at 90°, showing the side-by-side orientation of the great arteries resembling a “double-barrel shotgun.” Note that the aortic valve (AV) is more anterior and rightward of the pulmonic valve (PV) and arises from the morphologic right ventricle (RV) (systemic ventricle), consistent with d-TGA. The echodensity concerning for IE is incidentally noted en face (arrow) in the systemic venous baffle (SVB). PVB, Pulmonary venous baffle.

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  Figure 8. TEE, midesophageal view, with biplane imaging focused on the large echodensity concerning for IE (arrows). Subpulmonic stenosis (SubPS) is noted due to the bulging of the interventricular septum toward the lower-pressure morphologic left ventricle (LV) (subpulmonic ventricle). MV, Mitral valve; PV, pulmonic valve; PVB, pulmonary venous baffle; RV, right ventricle; SVB, systemic venous baffle; TV, tricuspid valve.

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  Figure 9. TEE, midesophageal view at 30°, with color flow Doppler imaging applied showing significant tricuspid regurgitation (arrow). LV, Left ventricle; PVB, pulmonary venous baffle; RV, right ventricle; SVB, systemic venous baffle.

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  Figure 10. TEE, midesophageal view at 0°, following the injection of agitated saline (“bubble study”). Note that the systemic venous baffle (SVB) and morphologic left ventricle (LV) (subpulmonic ventricle) are filled with bubbles, while the pulmonic venous baffle (PVB) and morphologic right ventricle (RV) (systemic ventricle) are not, indicating no evidence of a significant baffle leak.