Mechanical extraction of a pulmonary valve vegetation in a patient with endocarditis.

Abstract

A 44-year-old male known with small ventricular septal defect, but no previous history of intravenous drug abuse presented to an outside hospital with fever, chills, and back pain. A chest computed tomography showed multifocal nodular and consolidative pulmonary opacities with borderline enlarged mediastinal lymph nodes (Panel, A). Blood cultures grew Staphylococcus lugdunensis; given suspicion of infective endocarditis causing septic pulmonary emboli, he was transferred to our hospital. Transoesophageal echocardiography (TEE) on admission showed highly mobile masses attached to the native tricuspid (B) and to the sub-pulmonary area of the right ventricular outflow tract along with posterior leaflet perforation of the tricuspid valve with mild-to-moderate regurgitation (C). The sub-pulmonary lesion was in the path of the high-velocity left-to-right jet through the ventricular septal defect (D; Supplementary data online, Video S1), explaining the unusual location. Patient had persistent bacteremia despite appropriate antibiotic therapy and eventually developed haemoptysis and acute respiratory failure requiring intubation. At repeat TEE showed interval increase in the size of the sub-pulmonic vegetations. In the absence of haemodynamically significant lesions, the multidisciplinary team recommended percutaneous transcatheter mechanical vegectomy rather than surgical intervention.