An 85-year-old female with history of dementia presented with concern for severe sepsis and was found to have methicillin sensitive staphylococcus aureus bacteremia complicated by atrial fibrillation. For further workup, a transoesophageal echocardiography (TOE) was obtained. The study revealed a large echogenic density with multiple echolucent areas within the finding. There was evidence of blood flow in these echolucent areas based on color flow imaging. This mass was intermittently protruding into the left ventricle causing a function mitral stenosis. The collective findings on echocardiography, in context of bacteremia, were highly suggestive of mitral valve abscess (Figure 1).
Figure 1. Mitral valve abscess noted in multiple views by transoesophageal echocardiography.
(A): Bicommissural view of mitral valve abscess protruding into left atrium; (B): color flow doppler comparison view with evidence of color flow within the abscess; (C): surgeon's view in 3-dimensional with abscess involving the A2-P2 scallops; and (D): midesophageal long axis view.
She was initially treated with empiric broad-spectrum antibiotics and was deescalated based on anti-microbiology sensitivies. The cardiothoracic surgery team deemed that the patient was at prohibitive risk for surgery due to high frailty index, co-morbidities, and advanced age. The patient's condition acutely deteriorated with septic shock, requiring multiple vasoactive medications for hemodynamic instability and was endotracheally intubated for hypoxic respiratory failure. Due the poor prognosis of the patient, the family opted for palliative care management and surgical removal of mass was not pursued. The patient eventually expired with comfort measures implemented.
Our imaging case is of exceptional value in understanding the rare echocardiographic findings of probable infective abscess and 3-dimensional TOE highlights the precision in location of the mass and in understanding the behavior of the mass during cardiac cycle.