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PP-012 AN ADULT PATIENT WITH PATENT DUCTUS ARTERIOSUS: MULTIMODALITY DIAGNOSTIC APPROACH
Poster Presentations / International Journal of Cardiology 163S1 (2013) S81–S211
PP-010 BALL SHAPED THROMBUS IN ATRIAL SEPTAL ANEURYSM, EXTENDING FROM THE LEFT ATRIUM TO THE RIGHT ATRIUM VIA PFO 1 1 2 M. Gencaslan ¸ , P.T. Bayır1 , S. Cakal ¸ , B. Cakal ¸ , T.H. Efe1 , Z. Bayram1 . 1 2 Mus State Hospital, Turkey; Artvin State Hospital, Turkey A 56-year-old man with a history of hypertension and type 2 diabetes mellitus presented with palpitation for two months. Electrocardiography revealed atrial fibrillation with rapid ventricular response. After slowing the heart rate with intravenous metoprolol succinate, transthoracic echocardiography (TTE) was performed. In apical four chamber view; spontaneous echo contrast in the left atrium and echogenic mass adherent to the atrial septal aneurysm, were seen. Transesophageal echocardiography (TEE) was performed and an aneurysm of the interatrial septum with a patent foramen ovale (PFO) which was resulted left to right shunt, was seen. TEE revealed a large (1.57×1.71 cm), hyperechogenic thrombus attached to the atrial septal aneurysm and protruded into the right atrium via PFO during valsalva maneuver. There were spontaneous echo contrast in the left atrium and 10×11 mm thrombus formation in the left atrial appendage in the course of atrial fibrillation. The patient had no symptoms or signs suggestive of cryptogenic stroke or pulmonary embolism. The patient underwent a successful removal of atrial thrombi with closure of the PFO. Concomitant heparin and warfarin therapy were started. A therapeutic INR range was achieved and he was discharged from hospital without any complication. Although atrial thrombi have been reported in the presence of PFO previously, this unusual occurrence of thrombus in atrial septal aneurysm in the course of atrial fibrillation, go across a PFO is rare. This clinical case is an example of the left atrial thrombosis, extending to the right atrium via a PFO.
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an MCV of 98.3 fL. Platelet count was 134,000/mL. Erythrocyte sedimentation rate was 71 mm/hour. 2D and 3D Transthoracic echocardiography (TTE) (IE33 Matrix probe, Philips Medical systems, Bothell, WA, USA) revealed a mean left ventricular ejection fraction (EF) of 65%, Left heart chambers were in normal size. TTE detected a floopy mass arising from the anterior leaflet of the mitral valve and moderate mitral regurgitation at apical 4-chamber and parasternal long-axis windows (Figure 1) A subsequent real-time three dimensional transesophageal echocardiography (3D-RT TEE) also conducted for precise anatomic definition. Suprisingly 3D-RT revealed a 25×27 mm floppy vegetation on the posterior annulus of the mitral valve with moderate to severe mitral regurgitation (Figure 2). There was no additional cardiac abnormality. The patient was diagnosed as infective endocarditis. Treatment with intravenous amipisilin plus gentamisin was initially started. His serial blood culture results were persistently negative. On day 7 the patient developed dyspnea suggestive of heart failure therefore, the patient was referred to cardiac surgery after the medical therapy has been revised to intravenous vancomycin plus gentamisin. Vegetation was succesfully removed with surgery and after 6 weeks of antibiotic therapy the patient was discharged with total cure. In this case, realtime 3D echocardiography helped the cardiologist understand the morphologic characteristics and the precise localization and the attachment point of the vegetation.
Figure 1. (A) Parasternal long-axis window of TTE demonstrates a floopy vegetation; (B) TEE image from 100 degree midesophageal level revealed the vegetation; (C) TEE image from 120 degree midesophageal level showed vegetation and moderatesevere mitral regurgitation by color doppler echocardiography; (D) TEE image from X-plain 120 degree midesophageal level showed vegetation. Figure 2. (A) 3D-RT TTE with mitral valve vegetation (arrow). (B) 3D-RT TTE from left atrial perspective with the mitral valve vegetation (arrow); (C,D) 3D-RT TEE from left atrial perspective with vegetation (2.5×2.7 cm) involving the posterior annulus of the mitral valve (arrow).
Figure: Transesophageal echocardiography views of a large (1.57×1.71 cm) thrombus in atrial septal aneurysm.
PP-011 AN UNUSUAL CASE OF INFECTIVE ENDOCARDITIS: ANNULUS VEGETATION 1 O.S. Deveci1 , Z. Isılak ¸ , M. Yalcın ¸ 1 , M. Atalay2 , M. Uzun1 . 1 G¨ ulhane Askeri Tıp Akademisi Haydarpasa E˘gitim Hastanesi Kardiyoloji Anabilim Dalı, Turkey; 2 Merzifon Askeri Hastanesi Kardiyoloji B¨ ol¨ um¨ u, Turkey A 24-year-old man without any known cardiac disease was admitted to our hospital because of fever and general fatigue. On physical examination, his blood pressure was 125/75 mmHg, pulse was 100 beats per minute, temperature 39 degrees, the respiratory rate 20 breaths per minute, and the oxygen saturation 97% while he was breathing ambient air. The cardiovascular examination revealed a 3/6 holosystolic murmur in the left fourth intercostal space radiating to the axilla. The remainder of the examination was normal. Electrocardiography was sinus tachycardia. Laboratory data obtained on the admission revealed a white blood cell (WBC) count of 14,800/mL with 88% neutrophils, 10% lymphocytes, and 2% monocytes. Hemoglobin was 12.1 mg/dL with
PP-012 AN ADULT PATIENT WITH PATENT DUCTUS ARTERIOSUS: MULTIMODALITY DIAGNOSTIC APPROACH 1 , O.S. Deveci1 , M. Yalcın ¸ 1 , M. Atalay3 , M. I˙ ncedayı2 , Z. Isılak ¸ M. Uzun1 . 1 G¨ ulhane Askeri Tıp Akademisi Haydarpasa E˘gitim Hastanesi Kardiyoloji Anabilim Dalı, Turkey; 2 G¨ ulhane Askeri Tıp Akademisi Haydarpasa E˘gitim Hastanesi Radyoloji Anabilim Dalı, Turkey; 3 Merzifon Askeri Hastanesi Kardiyoloji B¨ ol¨ um¨ u, Turkey A 20-year-old man was admitted to the hospital with exertional dyspnea (NYHA Class 2). Auscultation of his chest revealed a harsh, grade 3/6 continuous murmur which was loudest at the second left intercostal space; there were no signs suggestive of volume overload, ventricular failure, or raised pulmonary pressures. Chest X-ray demonstrated mild cardiomegaly with normal pulmonary vasculature, and electrocardiogram revealed normal sinus rhythm with no features of ventricular strain or atrial enlargement. Transthoracic echocardiography (TTE) (IE33 Matrix probe, Philips Medical Systems, Bothell, WA, USA) revealed a mean left ventricular ejection fraction (EF) of 60%. Left heart chambers and pulmonary artery were dilated. Initial TTE showed a presence of a large (1.65 cm2) window-like patent ductus arteriosus (PDA) in the suprasternal notch view. Color floor M-mode echocardiography demonstrated a continious left to right shunting from the aorta into the left pulmonary artery
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Poster Presentations / International Journal of Cardiology 163S1 (2013) S81–S211
(Figure 1A,B). 2D Transesophageal echocardiography (TEE) revealed a large window-like PDA (Figure 1C,D). A subsequent real-time three dimensional transesophageal echocardiography (3D RT-TEE) revealed the presence of a large PDA (1.65 cm2) (Figure 1E). Contrast enhanced thorax computed tomography (CT) demonstrated a large PDA with no additional cardiac abnormality (Figure 2). The patient was referred to cardiac surgery.
Figure 1. (A) Apical 4-chamber window of TTE demonstrated dilated left heart chambers. (B) Color flow M-mode TTE image: continuous left to right shunting from the aorta into the left pulmonary artery. (C) Color flow M-mode TEE image from 0 degree upper esophageal level: a large PDA. (D) Continuous Doppler TEE image from 0 degree upper esophageal level: continuous left to right shunting from the aorta into the left pulmonary artery. (E) 3D RT TEE: The entry of the PDA from the aortic perspective. Figure 2. (A) CT revealed the enlarged caliber of pulmonary artery and a large PDA between aorta and the left pulmonary artery. (B) CT from oblique cross-section: Markedly enlarged pulmonary artery and a large PDA.
PP-013 METASTATIC GIANT PARACARDIAC LEIOMYOSARCOMA: MULTIMODALITY DIAGNOSTIC APPROACH 1 O.S. Deveci1 , Z. Isılak ¸ , M. Yalcın ¸ 1 , M. Atalay3 , M. I˙ ncedayı2 , M. Uzun1 . 1 G¨ ulhane Askeri Tıp Akademisi Haydarpasa E˘gitim Hastanesi Kardiyoloji Anabilim Dalı, Turkey; 2 G¨ ulhane Askeri Tıp Akademisi Haydarpasa E˘gitim Hastanesi Radyoloji Anabilim Dalı, Turkey; 3 Merzifon Askeri Hastanesi Kardiyoloji B¨ ol¨ um¨ u, Turkey
were detected at parasternal long axis. There were no signs of compression of the left ventricle and left atrium (Figure 1A) and no other intracardiac congenital anomalies were detected. Apical 4-chamber and subcostal view of the real time 3D-TTE revealed a giant heterogeneous mass (128×93 mm) adjacent to the left heart chambers (Figures 1B–D). Thoracoabdominal contrast enhanced magnetic resonance (MR) imaging demonstrated the lack of enhancement of the giant mass (110×100×80 mm) (Figure 2). The patient was referred to the thoracic surgery. Pathological diagnosis of the mass after formal surgical removal was leiomyosarcoma. PP-014 ANTERIOR MITRAL LEAFLET PERFORATION AND AORTIC VEGETATION DUE TO INFECTIVE ENDOCARDITIS EVALUATED BY THREE-DIMENSIONAL ECHOCARDIOGRAPHY S. Demirkol, M. Unlu, S. ¸ Balta, U.C. ¸ Yuksel, ¨ Z. Arslan, U. Ku¨ c¸ uk, ¨ T. Celik. ¸ Department of Cardiology, Gulhane Medical Faculty, Ankara, Turkey Complicated left-sided native valve infective endocarditis remains a serious disease with significant morbidity and mortality. Mitral perforations are rare complications of destructive endocarditis. A 50-year-old woman have applied for fever and shortness of breath for 3 months. Electrocardiography showed a sinus tachycardia. Twodimensional transthoracic echocardiography demonstrated severe mitral and aortic regurgitation. Two-dimensional transesophageal echocardiography (2D-TEE) revealed mitral valve perforation and aortic valve vegetation (Figure and video 1A), also severe aortic and mitral regurtitation because of destructive endocarditis (Figure and video 1B).
A 56-year-old woman was admitted to hospital with shortness of breath. Her past medical history included mild dyslipidemia and a uterine leiomyosarcoma surgery 12 years ago. Blood pressure was 130/70 mmHg. The pulse was rhythmic and had a rate of 102/min. The patient had lower abdominal tenderness. The oscultation of the breath sounds revealed decreasing sounds towards the middle zone of the lungs. Normal sinus rhythm was detected with ECG.
Figure 1. (A) Parasternal long axis window of TTE: M (arrow). (B) Apical 4-chamber window of TTE: M.(arrow); (C) Parasternal long axis view of real time 3D TTE: M.(arrow), (D) The post-processing analysis of the reconstructed 3D images. The image with green frame demonstrates a giant mass. The image with red frame is orthogonal to the image with green frame, demonstrates similar findings. Figure 2. (A) Axial T1-weighted MR image: A 110×100×80 mm size of hypointense mass lesion with smooth contours in the pelvis of the patient with a history of surgical management of leiomyosarcoma. (B) Coronal T2-weighted MRI image shows a mass lesion causing diaphragmatic elevation in the left upper abdominal quadrant and left lower thorax with size of 210×120×120 mm. (C) Axial T2-Weighted MRI image at the level of the hearth shows the mass lesion in contact with left ventricle. Obliteration of pericardial fat planes between left ventricle and the mass lesion is suspicious for cardiac invasion. M: Mass, RA: Right atrium, RV: Right ventricle, L: Liver, LV: Left ventricle, LA: Left atrium.
Two-dimensional transthoracic echocardiography (TTE) (IE33 Matrix probe, Philips Medical Systems, Bothell, WA, USA) detected normal left ventricle systolic functions with a left ventricle ejection fraction of 62%. A giant mass adjacent to the left heart chambers
Figure 1: (A) Two-dimensional transesophageal echocardiography showing mitral valve perforation and aortic valve vegetation. (B) Two-dimensional transesophageal echocardiography displaying severe aortic and mitral regurgitation because of destructive endocarditis. (C) 3D zoom modality TEE displaying mitral valve perforation at A2 scallop. (D) 3D zoom modality TEE showing vegetation at the aortic valve. LV: left ventricle, Ao: aorta, arrow: perforation of anterior mitral valve, asterisk: aortic vegetation.
To better define this pathology, we performed three dimensional transesophageal echocardiography (3D-TEE). 3D zoom modality TEE displayed mitral valve perforation at A2 scallop (Figure 1C) and vegetation at the aortic valve (Figure 1D). Infective endocarditis is a life-threatening disease still associated with a high mortality rate despite recent advances in diagnostic imaging, antimicrobial, and surgical therapies. Aortic valve is primarily affected in the leftsided endocarditis, then mitral anterior leaflet is involved due to aortic regurgitation. Mitral anterior leaflet endocarditis may cause aneurysmal formation and then it can lead to mitral perforation. The sensitivity of TTE ranges from 40 to 63% while that of TEE
PP-010 BALL SHAPED THROMBUS IN ATRIAL SEPTAL ANEURYSM, EXTENDING FROM THE LEFT ATRIUM TO THE RIGHT ATRIUM VIA PFO 1 1 2 M. Gencaslan ¸ , P.T. Bayır1 , S. Cakal ¸ , B. Cakal ¸ , T.H. Efe1 , Z. Bayram1 . 1 2 Mus State Hospital, Turkey; Artvin State Hospital, Turkey A 56-year-old man with a history of hypertension and type 2 diabetes mellitus presented with palpitation for two months. Electrocardiography revealed atrial fibrillation with rapid ventricular response. After slowing the heart rate with intravenous metoprolol succinate, transthoracic echocardiography (TTE) was performed. In apical four chamber view; spontaneous echo contrast in the left atrium and echogenic mass adherent to the atrial septal aneurysm, were seen. Transesophageal echocardiography (TEE) was performed and an aneurysm of the interatrial septum with a patent foramen ovale (PFO) which was resulted left to right shunt, was seen. TEE revealed a large (1.57×1.71 cm), hyperechogenic thrombus attached to the atrial septal aneurysm and protruded into the right atrium via PFO during valsalva maneuver. There were spontaneous echo contrast in the left atrium and 10×11 mm thrombus formation in the left atrial appendage in the course of atrial fibrillation. The patient had no symptoms or signs suggestive of cryptogenic stroke or pulmonary embolism. The patient underwent a successful removal of atrial thrombi with closure of the PFO. Concomitant heparin and warfarin therapy were started. A therapeutic INR range was achieved and he was discharged from hospital without any complication. Although atrial thrombi have been reported in the presence of PFO previously, this unusual occurrence of thrombus in atrial septal aneurysm in the course of atrial fibrillation, go across a PFO is rare. This clinical case is an example of the left atrial thrombosis, extending to the right atrium via a PFO.
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an MCV of 98.3 fL. Platelet count was 134,000/mL. Erythrocyte sedimentation rate was 71 mm/hour. 2D and 3D Transthoracic echocardiography (TTE) (IE33 Matrix probe, Philips Medical systems, Bothell, WA, USA) revealed a mean left ventricular ejection fraction (EF) of 65%, Left heart chambers were in normal size. TTE detected a floopy mass arising from the anterior leaflet of the mitral valve and moderate mitral regurgitation at apical 4-chamber and parasternal long-axis windows (Figure 1) A subsequent real-time three dimensional transesophageal echocardiography (3D-RT TEE) also conducted for precise anatomic definition. Suprisingly 3D-RT revealed a 25×27 mm floppy vegetation on the posterior annulus of the mitral valve with moderate to severe mitral regurgitation (Figure 2). There was no additional cardiac abnormality. The patient was diagnosed as infective endocarditis. Treatment with intravenous amipisilin plus gentamisin was initially started. His serial blood culture results were persistently negative. On day 7 the patient developed dyspnea suggestive of heart failure therefore, the patient was referred to cardiac surgery after the medical therapy has been revised to intravenous vancomycin plus gentamisin. Vegetation was succesfully removed with surgery and after 6 weeks of antibiotic therapy the patient was discharged with total cure. In this case, realtime 3D echocardiography helped the cardiologist understand the morphologic characteristics and the precise localization and the attachment point of the vegetation.
Figure 1. (A) Parasternal long-axis window of TTE demonstrates a floopy vegetation; (B) TEE image from 100 degree midesophageal level revealed the vegetation; (C) TEE image from 120 degree midesophageal level showed vegetation and moderatesevere mitral regurgitation by color doppler echocardiography; (D) TEE image from X-plain 120 degree midesophageal level showed vegetation. Figure 2. (A) 3D-RT TTE with mitral valve vegetation (arrow). (B) 3D-RT TTE from left atrial perspective with the mitral valve vegetation (arrow); (C,D) 3D-RT TEE from left atrial perspective with vegetation (2.5×2.7 cm) involving the posterior annulus of the mitral valve (arrow).
Figure: Transesophageal echocardiography views of a large (1.57×1.71 cm) thrombus in atrial septal aneurysm.
PP-011 AN UNUSUAL CASE OF INFECTIVE ENDOCARDITIS: ANNULUS VEGETATION 1 O.S. Deveci1 , Z. Isılak ¸ , M. Yalcın ¸ 1 , M. Atalay2 , M. Uzun1 . 1 G¨ ulhane Askeri Tıp Akademisi Haydarpasa E˘gitim Hastanesi Kardiyoloji Anabilim Dalı, Turkey; 2 Merzifon Askeri Hastanesi Kardiyoloji B¨ ol¨ um¨ u, Turkey A 24-year-old man without any known cardiac disease was admitted to our hospital because of fever and general fatigue. On physical examination, his blood pressure was 125/75 mmHg, pulse was 100 beats per minute, temperature 39 degrees, the respiratory rate 20 breaths per minute, and the oxygen saturation 97% while he was breathing ambient air. The cardiovascular examination revealed a 3/6 holosystolic murmur in the left fourth intercostal space radiating to the axilla. The remainder of the examination was normal. Electrocardiography was sinus tachycardia. Laboratory data obtained on the admission revealed a white blood cell (WBC) count of 14,800/mL with 88% neutrophils, 10% lymphocytes, and 2% monocytes. Hemoglobin was 12.1 mg/dL with
PP-012 AN ADULT PATIENT WITH PATENT DUCTUS ARTERIOSUS: MULTIMODALITY DIAGNOSTIC APPROACH 1 , O.S. Deveci1 , M. Yalcın ¸ 1 , M. Atalay3 , M. I˙ ncedayı2 , Z. Isılak ¸ M. Uzun1 . 1 G¨ ulhane Askeri Tıp Akademisi Haydarpasa E˘gitim Hastanesi Kardiyoloji Anabilim Dalı, Turkey; 2 G¨ ulhane Askeri Tıp Akademisi Haydarpasa E˘gitim Hastanesi Radyoloji Anabilim Dalı, Turkey; 3 Merzifon Askeri Hastanesi Kardiyoloji B¨ ol¨ um¨ u, Turkey A 20-year-old man was admitted to the hospital with exertional dyspnea (NYHA Class 2). Auscultation of his chest revealed a harsh, grade 3/6 continuous murmur which was loudest at the second left intercostal space; there were no signs suggestive of volume overload, ventricular failure, or raised pulmonary pressures. Chest X-ray demonstrated mild cardiomegaly with normal pulmonary vasculature, and electrocardiogram revealed normal sinus rhythm with no features of ventricular strain or atrial enlargement. Transthoracic echocardiography (TTE) (IE33 Matrix probe, Philips Medical Systems, Bothell, WA, USA) revealed a mean left ventricular ejection fraction (EF) of 60%. Left heart chambers and pulmonary artery were dilated. Initial TTE showed a presence of a large (1.65 cm2) window-like patent ductus arteriosus (PDA) in the suprasternal notch view. Color floor M-mode echocardiography demonstrated a continious left to right shunting from the aorta into the left pulmonary artery
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Poster Presentations / International Journal of Cardiology 163S1 (2013) S81–S211
(Figure 1A,B). 2D Transesophageal echocardiography (TEE) revealed a large window-like PDA (Figure 1C,D). A subsequent real-time three dimensional transesophageal echocardiography (3D RT-TEE) revealed the presence of a large PDA (1.65 cm2) (Figure 1E). Contrast enhanced thorax computed tomography (CT) demonstrated a large PDA with no additional cardiac abnormality (Figure 2). The patient was referred to cardiac surgery.
Figure 1. (A) Apical 4-chamber window of TTE demonstrated dilated left heart chambers. (B) Color flow M-mode TTE image: continuous left to right shunting from the aorta into the left pulmonary artery. (C) Color flow M-mode TEE image from 0 degree upper esophageal level: a large PDA. (D) Continuous Doppler TEE image from 0 degree upper esophageal level: continuous left to right shunting from the aorta into the left pulmonary artery. (E) 3D RT TEE: The entry of the PDA from the aortic perspective. Figure 2. (A) CT revealed the enlarged caliber of pulmonary artery and a large PDA between aorta and the left pulmonary artery. (B) CT from oblique cross-section: Markedly enlarged pulmonary artery and a large PDA.
PP-013 METASTATIC GIANT PARACARDIAC LEIOMYOSARCOMA: MULTIMODALITY DIAGNOSTIC APPROACH 1 O.S. Deveci1 , Z. Isılak ¸ , M. Yalcın ¸ 1 , M. Atalay3 , M. I˙ ncedayı2 , M. Uzun1 . 1 G¨ ulhane Askeri Tıp Akademisi Haydarpasa E˘gitim Hastanesi Kardiyoloji Anabilim Dalı, Turkey; 2 G¨ ulhane Askeri Tıp Akademisi Haydarpasa E˘gitim Hastanesi Radyoloji Anabilim Dalı, Turkey; 3 Merzifon Askeri Hastanesi Kardiyoloji B¨ ol¨ um¨ u, Turkey
were detected at parasternal long axis. There were no signs of compression of the left ventricle and left atrium (Figure 1A) and no other intracardiac congenital anomalies were detected. Apical 4-chamber and subcostal view of the real time 3D-TTE revealed a giant heterogeneous mass (128×93 mm) adjacent to the left heart chambers (Figures 1B–D). Thoracoabdominal contrast enhanced magnetic resonance (MR) imaging demonstrated the lack of enhancement of the giant mass (110×100×80 mm) (Figure 2). The patient was referred to the thoracic surgery. Pathological diagnosis of the mass after formal surgical removal was leiomyosarcoma. PP-014 ANTERIOR MITRAL LEAFLET PERFORATION AND AORTIC VEGETATION DUE TO INFECTIVE ENDOCARDITIS EVALUATED BY THREE-DIMENSIONAL ECHOCARDIOGRAPHY S. Demirkol, M. Unlu, S. ¸ Balta, U.C. ¸ Yuksel, ¨ Z. Arslan, U. Ku¨ c¸ uk, ¨ T. Celik. ¸ Department of Cardiology, Gulhane Medical Faculty, Ankara, Turkey Complicated left-sided native valve infective endocarditis remains a serious disease with significant morbidity and mortality. Mitral perforations are rare complications of destructive endocarditis. A 50-year-old woman have applied for fever and shortness of breath for 3 months. Electrocardiography showed a sinus tachycardia. Twodimensional transthoracic echocardiography demonstrated severe mitral and aortic regurgitation. Two-dimensional transesophageal echocardiography (2D-TEE) revealed mitral valve perforation and aortic valve vegetation (Figure and video 1A), also severe aortic and mitral regurtitation because of destructive endocarditis (Figure and video 1B).
A 56-year-old woman was admitted to hospital with shortness of breath. Her past medical history included mild dyslipidemia and a uterine leiomyosarcoma surgery 12 years ago. Blood pressure was 130/70 mmHg. The pulse was rhythmic and had a rate of 102/min. The patient had lower abdominal tenderness. The oscultation of the breath sounds revealed decreasing sounds towards the middle zone of the lungs. Normal sinus rhythm was detected with ECG.
Figure 1. (A) Parasternal long axis window of TTE: M (arrow). (B) Apical 4-chamber window of TTE: M.(arrow); (C) Parasternal long axis view of real time 3D TTE: M.(arrow), (D) The post-processing analysis of the reconstructed 3D images. The image with green frame demonstrates a giant mass. The image with red frame is orthogonal to the image with green frame, demonstrates similar findings. Figure 2. (A) Axial T1-weighted MR image: A 110×100×80 mm size of hypointense mass lesion with smooth contours in the pelvis of the patient with a history of surgical management of leiomyosarcoma. (B) Coronal T2-weighted MRI image shows a mass lesion causing diaphragmatic elevation in the left upper abdominal quadrant and left lower thorax with size of 210×120×120 mm. (C) Axial T2-Weighted MRI image at the level of the hearth shows the mass lesion in contact with left ventricle. Obliteration of pericardial fat planes between left ventricle and the mass lesion is suspicious for cardiac invasion. M: Mass, RA: Right atrium, RV: Right ventricle, L: Liver, LV: Left ventricle, LA: Left atrium.
Two-dimensional transthoracic echocardiography (TTE) (IE33 Matrix probe, Philips Medical Systems, Bothell, WA, USA) detected normal left ventricle systolic functions with a left ventricle ejection fraction of 62%. A giant mass adjacent to the left heart chambers
Figure 1: (A) Two-dimensional transesophageal echocardiography showing mitral valve perforation and aortic valve vegetation. (B) Two-dimensional transesophageal echocardiography displaying severe aortic and mitral regurgitation because of destructive endocarditis. (C) 3D zoom modality TEE displaying mitral valve perforation at A2 scallop. (D) 3D zoom modality TEE showing vegetation at the aortic valve. LV: left ventricle, Ao: aorta, arrow: perforation of anterior mitral valve, asterisk: aortic vegetation.
To better define this pathology, we performed three dimensional transesophageal echocardiography (3D-TEE). 3D zoom modality TEE displayed mitral valve perforation at A2 scallop (Figure 1C) and vegetation at the aortic valve (Figure 1D). Infective endocarditis is a life-threatening disease still associated with a high mortality rate despite recent advances in diagnostic imaging, antimicrobial, and surgical therapies. Aortic valve is primarily affected in the leftsided endocarditis, then mitral anterior leaflet is involved due to aortic regurgitation. Mitral anterior leaflet endocarditis may cause aneurysmal formation and then it can lead to mitral perforation. The sensitivity of TTE ranges from 40 to 63% while that of TEE