Left Atrial Appendage Confusion: A Mobile Echodensity in a Patient With Endocarditis

Abstract

A 50-YEAR-OLD, 70- kg, 172- cm man with known bicuspid aortic valve disease and severe aortic insufficiency presented to the authors’ institution with a 3-day history of “pulsating” chest pain, dyspnea with exertion, and bilateral lower extremity swelling. The patient previously was hospitalized on several occasions for the treatment of recurrent Streptococcus cristatus bacteremia originating from poor dentition. He also was receiving apixaban for the treatment of a cephalic vein thrombosis. The physical examination was notable for sinus tachycardia (122 beats/min), grade III/VI systolic and diastolic murmurs heard best at the left sternal border, bilateral lower extremity pitting edema, and red petechiae on both hands and feet. The patient was anemic (hemoglobin of 8.0 g/dL) and had renal insufficiency (serum creatinine concentration of 1.66 mg/dL). Leukocytosis was present (11.8 103/µL). The plasma brain natriuretic peptide level was markedly elevated (20,063 pg/mL). An increase in high-sensitivity troponin concentration also was observed. An electrocardiogram revealed sinus tachycardia and low-voltage QRS complexes, but acute ST-segment changes were absent. Transthoracic echocardiogram revealed vegetations on both the aortic and mitral valves, resulting in severe regurgitation. Transesophageal echocardiography (TEE) also was performed as part of the diagnostic evaluation, and the following images were obtained (Fig. 1-3; Videos 1-3). What is the diagnosis?