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Two-dimensional echocardiography of ruptured pulmonic valve with infective endocarditis
Volume 107 Number 5, Part 1
Brie[ Communications
1027
are not clear, since there was previously no way of diagnosing and following these patients. We elected to treat the patient conservatively: the hemodynamic lesion was mild and there was no clinical residual infective endocarditis despite the persistent echo-dense mass within the aneurysm. Nine months later, the patient was completely asymptomatic. An increase in the size of the aneurysm or a change in the hemodynamic status of the patient would make us favor surgical repair of the defect. REFERENCES
1. Sakakibara S, Konno S: Congenital aneurysm of sinus of Valsalva. A clinical study. AM HZARTJ 63:708, 1962. 2. Conde CA, Meller J, Donoso E, Dack S: Bacterial endocarditis with ruptured sinus of Valsalva and aortico-cardiac fistula. Am J Cardiol 35:912, 1975. 3. Boutefeu JM, Moret PR, Hahn C, Hauf E: Aneurysms of the sinus of Valsalva. Report of seven cases and review of the literature. Am J Med 65:18, 1978. 4. Fishbein MC, Obma R, Roberts WC: Unruptured sinus of Valsalva aneurysm. Am J Cardiol 35:918, 1975. 5. Nishimura K, Hibi N, Kato T, Fukui Y, Arakawa T, Tatematsu H, Miwa A, Tada H, Kambe T, Sakamoto N: Real-time observation of ruptured right sinus of Valsalva aneurysm by high speed ultrasonocardiotomography. Circulation 53:732, 1976. 6. DeMaria AN, Bommer W, Neumann A, Weinert L, Bogren H, Mason DT: Identification and localization of aneurysms of the ascending aorta by cross-sectional echocardiography. Circulation 59:755, 1979. 7. Engel PJ, Held JS, van der Bel-Kahn J, Spitz H: Echocardiographic diagnosis of congenital sinus of Valsalva aneurysm with dissection of the interventricular septum. Circulation 63:705, 1981.
Two-dimensional echocardiography of ruptured pulmonic valve with infective endocarditis Michihiro Suwa, M.D., Gen Shimizu, M.D., Yoshinori Doi, M.D., Masaya Kino, M.D., Yuzo Hirota, M.D., Shin-ichiro Kubo, M.D., Keishiro Kawamura, M.D., Takashi Nishimoto, M.D., Masamichi Maeda, M.D., Kunio Asada, M.D., Shinjiro Sasaki, M.D., and Atsuro Takeuchi, M.D. Takatsuki City, Osaka, J a p a n
Two-dimensional echocardiography (2DE) is well known to be a useful tool for spatial information about disordered valves, especially with the presence of vegetations. Although M-mode echocardiographic findings of pulmonic valve involvement of infective endocarditis have accu-
From the Third Division, Department of Internal Medicine, and the Department of Thoracic and Cardiovascular Surgery, Osaka Medical College, Takatsuki City. Reprint requests:Dr. Michihiro Suwa, The Third Division,Department of Internal Medicine, Osaka Medical College, 2-7, Daigaku-cho, Takatsuki City, Osaka, Japan, 569-MZ.
Fig. 1. A two-dimensional echocardiogram (2DE) of right parasternal short-axis view at the level of the right ventricular outflow tract and main pulmonary artery during diastole on admission. A shaggy echo prolapsing into the right ventricular outflow tract was seen during diastole (white arrow). AO = ascending aorta; P A = main pulmonary artery; R V = right ventricle.
mulated in the literature, 1-6 2DE findings of ruptured pulmonic valve have not been reported. Recently, we experienced a case of right-sided infective endocarditis involving the pulmonic valve in a patient with ventricular septal defect. Described here are the 2DE findings of ruptured pulmonic valve. A 33-year-old man was admitted to the hospital with a 5-month history of fever and dry cough. He was known to have ventricular septal defect and dextroversion of the heart since childhood. He had a history of severe alcohol abuse for more than 15 years, but denied any history of narcotic abuse. On examination, a grade 3/6 midsystolic ejection murmur and a 3/6 early to mid-diastolic diamond-shaped murmur were heard at the third right intercostal space; both of these murmurs were accentuated with inspiration. The liver was enlarged and jaundice was present, but the spleen was not enlarged. Jugular veins were not distended. Multiple blood cultures yielded positive results for Streptococcus viridans. Echocardiographic examination on admission revealed that mitral and aortic valves showed normal configuration and anatomic position. In the right ventricular outflow tract, a shaggy echo was seen to prolapse from the pulmonic valve into the right ventricle only during diastole, hut no abnormal dense echo could be demonstrated during systole, either in the pulmonary artery or right ventricle (Fig. 1). Repeat echocardiographic examination showed that the shaggy echo oscillated during diastole and its prolapse into the right ventricular outflow tract became gradually more apparent as the diastolic murmur increased in intensity (Figs. 2 and 3). The posterior leaflet of the pulmonic valve appeared somewhat thickened and was considered to have a vegetation upon it; diastolic oscillation of the tricuspid valve was also present. The hospital course was complicated with repeated septic
May, 1984
1028
----Brie/Communications
Ame,ica,HeartJournal
RV
PA
6/4/8 I H Y. 3 3 M
Fig. 2. M-mode scan from the right ventricular outflow tract to the main pulmonary artery on the one hundredth hospital day. The shaggy echoes vibrated in the right ventricular outflow tract during diastole. Some thickening suggestive of vegetations was seen in the posterior leaflet of the pulmonic valve.
Fig. 3. 2DEs of right parasternal short-axis view at the level of the right ventricular outflow tract and main pulmonary artery during diastole (A) and systole (B) on the one hundredth hospital day. A, The prolapse of the shaggy echo into the right ventricular outflow tract during diastole (white arrow) became more apparent compared with the admission 2DE. B, No abnormal echo was demonstrated either in the main pulmonary artery or the right ventricle during systole.
pulmonary embolism and acute renal failure, but these events were successfully treated. Pulmonic valve replacement was performed on the one hundred eleventh hospital day without preceding cardiac catheterization. A small subaortic ventricular septal defect was repaired with direct suture. Rupture and small vegetations (1 mm in size) of the septal leaflet and small vegetations of the posterior leaflet of the pulmonic valve were present (Fig. 4). The valve was replaced with a St. Jude Medical prosthesis. The patient was discharged in good condition.
Echocardiographic findings of right-sided infective endocarditis with pulmonic valve vegetation have been reported recently. 1-6Initially we thought that this case had pulmonic valve vegetation and that septic emboli were originating from this vegetation. Although the infective process was controlled and embolic episodes ceased, this abnormal shaggy echo in the right ventricular outflow tract during diastole became larger with clinical evidence of increased pulmonic regurgitation. The characteristic finding of this case was that the oscillating shaggy echo was present in the right ventricular outflow tract during
Volume 107 Number 5, Part 1
Brie/Communications
1029
Fig. 4. Rupture of the septal leaflet of the pulmonic valve (white arrow) was found at the level of the pulmonic ring and small vegetations were present on that and the posterior leaflets at surgery.
diastole, but no abnormal echoes were seen in the pulmonary artery or in the right ventricle during systole. These findings persisted until the time of operation, and a ruptured septal leaflet with very small vegetations was found at the time of operation. It was considered that the ruptured pulmonic leaflet was floating in the right ventricle during diastole, but this leaflet was attached closely to the pulmonary arterial wall during systole because of the high velocity of the blood stream. Thus oscillating shaggy echoes seen in the right ventricular outflow tract only during diastole may be a characteristic of ruptured pulmonic valve with or without vegetations.
REFERENCES
1. Kramer NE, Gill SS, Patel R, Towne WD: Pulmonary valve vegetations detected with echocardiography. Am J Cardiol 39:1064, 1977. 2. Dzindzio BS, Meyer L, Osterholm R, Hopeman A, Woltjen J, Forker AD: Isolated gonococcal pulmonary valve endocarditis: Diagnosis by echocardiography. Circulation 59:1319, 1979. 3. Okumachi F, Yoshikawa J, Takatsuka K, Owaki T, Kato H, Yanagihara K, Takagi Y, Shingaki M, Baba K, Tomita Y, Fukaya T, Tatemichi K, Shomura T, Yoshizumi M: Crosssectional echocardiographic diagnosis of pulmonary valve vegetation. J Cardiogr 9:279, 1979. 4. Melvin ET, Berger M, Lutzker LG, Goldberg E, Mildvan D: Noninvasive methods for detection of valve vegetations in infective endocarditis. Am J Cardiol 47:271, 1981. 5. Sharma S, Katdare AD, Munsi SC, Kinare SG: M-mode echographic detection of pulmonic valve infective endocarditis. AM HEARTJ 102:131, 1981. 6. Chiang CW, Lee YS, Chang CH, Hung JS, Chen L: Preoperative and postoperative bchocardiographic studies of pulmonic valvular endocarditis. Chest 80:232, 1981.
Echographic premature pulmonic valve opening: Sign of reduced right ventricular distensibility Fernando Benito, M.D., Jos~ Lopez-Send6n, M.D., Jos~ Oliver, M.D., Miguel A. Garcia-Fernandez, M.D., Isabel Coma-Canella, M.D., and Federico Lomberas, M.D. Madrid, Spain.
Under normal conditions the pulmonic valve is closed during ventricular diastole, opening during systole when right ventricular (RV) pressure exceeds pulmonary artery pressure. Atrial contraction produces a small doming of the pulmonic leaflets that can be appreciated in the M-mode echocardiogram as a posterior deflection of the pulmonic valve. In some circumstances a powerful atrial contraction may cause the pulmonic valve to open. ~Opening of the pulmonic valve before atrial contraction (premature valve opening) has been previously described in situations of RV volume overload, ~,:~ as well as in cases with restriction of diastolic filling to the right heart2, 4 In the present report, the M-mode echocardiographic and hemodynamic findings in 10 patients with premature pulmonic valve opening were studied with special reference to data indicative of reduced RV distensibility. Eight patients were men and two were women; their ages ranged From the Cardiologyand Coronary Care Unit, Department of Internal Medicine, La Paz, Universidad Autonoma. Reprint requests: Fernando Benito, c/ Valderrey 24-6°C, Madrid 29, Spain.
Brie[ Communications
1027
are not clear, since there was previously no way of diagnosing and following these patients. We elected to treat the patient conservatively: the hemodynamic lesion was mild and there was no clinical residual infective endocarditis despite the persistent echo-dense mass within the aneurysm. Nine months later, the patient was completely asymptomatic. An increase in the size of the aneurysm or a change in the hemodynamic status of the patient would make us favor surgical repair of the defect. REFERENCES
1. Sakakibara S, Konno S: Congenital aneurysm of sinus of Valsalva. A clinical study. AM HZARTJ 63:708, 1962. 2. Conde CA, Meller J, Donoso E, Dack S: Bacterial endocarditis with ruptured sinus of Valsalva and aortico-cardiac fistula. Am J Cardiol 35:912, 1975. 3. Boutefeu JM, Moret PR, Hahn C, Hauf E: Aneurysms of the sinus of Valsalva. Report of seven cases and review of the literature. Am J Med 65:18, 1978. 4. Fishbein MC, Obma R, Roberts WC: Unruptured sinus of Valsalva aneurysm. Am J Cardiol 35:918, 1975. 5. Nishimura K, Hibi N, Kato T, Fukui Y, Arakawa T, Tatematsu H, Miwa A, Tada H, Kambe T, Sakamoto N: Real-time observation of ruptured right sinus of Valsalva aneurysm by high speed ultrasonocardiotomography. Circulation 53:732, 1976. 6. DeMaria AN, Bommer W, Neumann A, Weinert L, Bogren H, Mason DT: Identification and localization of aneurysms of the ascending aorta by cross-sectional echocardiography. Circulation 59:755, 1979. 7. Engel PJ, Held JS, van der Bel-Kahn J, Spitz H: Echocardiographic diagnosis of congenital sinus of Valsalva aneurysm with dissection of the interventricular septum. Circulation 63:705, 1981.
Two-dimensional echocardiography of ruptured pulmonic valve with infective endocarditis Michihiro Suwa, M.D., Gen Shimizu, M.D., Yoshinori Doi, M.D., Masaya Kino, M.D., Yuzo Hirota, M.D., Shin-ichiro Kubo, M.D., Keishiro Kawamura, M.D., Takashi Nishimoto, M.D., Masamichi Maeda, M.D., Kunio Asada, M.D., Shinjiro Sasaki, M.D., and Atsuro Takeuchi, M.D. Takatsuki City, Osaka, J a p a n
Two-dimensional echocardiography (2DE) is well known to be a useful tool for spatial information about disordered valves, especially with the presence of vegetations. Although M-mode echocardiographic findings of pulmonic valve involvement of infective endocarditis have accu-
From the Third Division, Department of Internal Medicine, and the Department of Thoracic and Cardiovascular Surgery, Osaka Medical College, Takatsuki City. Reprint requests:Dr. Michihiro Suwa, The Third Division,Department of Internal Medicine, Osaka Medical College, 2-7, Daigaku-cho, Takatsuki City, Osaka, Japan, 569-MZ.
Fig. 1. A two-dimensional echocardiogram (2DE) of right parasternal short-axis view at the level of the right ventricular outflow tract and main pulmonary artery during diastole on admission. A shaggy echo prolapsing into the right ventricular outflow tract was seen during diastole (white arrow). AO = ascending aorta; P A = main pulmonary artery; R V = right ventricle.
mulated in the literature, 1-6 2DE findings of ruptured pulmonic valve have not been reported. Recently, we experienced a case of right-sided infective endocarditis involving the pulmonic valve in a patient with ventricular septal defect. Described here are the 2DE findings of ruptured pulmonic valve. A 33-year-old man was admitted to the hospital with a 5-month history of fever and dry cough. He was known to have ventricular septal defect and dextroversion of the heart since childhood. He had a history of severe alcohol abuse for more than 15 years, but denied any history of narcotic abuse. On examination, a grade 3/6 midsystolic ejection murmur and a 3/6 early to mid-diastolic diamond-shaped murmur were heard at the third right intercostal space; both of these murmurs were accentuated with inspiration. The liver was enlarged and jaundice was present, but the spleen was not enlarged. Jugular veins were not distended. Multiple blood cultures yielded positive results for Streptococcus viridans. Echocardiographic examination on admission revealed that mitral and aortic valves showed normal configuration and anatomic position. In the right ventricular outflow tract, a shaggy echo was seen to prolapse from the pulmonic valve into the right ventricle only during diastole, hut no abnormal dense echo could be demonstrated during systole, either in the pulmonary artery or right ventricle (Fig. 1). Repeat echocardiographic examination showed that the shaggy echo oscillated during diastole and its prolapse into the right ventricular outflow tract became gradually more apparent as the diastolic murmur increased in intensity (Figs. 2 and 3). The posterior leaflet of the pulmonic valve appeared somewhat thickened and was considered to have a vegetation upon it; diastolic oscillation of the tricuspid valve was also present. The hospital course was complicated with repeated septic
May, 1984
1028
----Brie/Communications
Ame,ica,HeartJournal
RV
PA
6/4/8 I H Y. 3 3 M
Fig. 2. M-mode scan from the right ventricular outflow tract to the main pulmonary artery on the one hundredth hospital day. The shaggy echoes vibrated in the right ventricular outflow tract during diastole. Some thickening suggestive of vegetations was seen in the posterior leaflet of the pulmonic valve.
Fig. 3. 2DEs of right parasternal short-axis view at the level of the right ventricular outflow tract and main pulmonary artery during diastole (A) and systole (B) on the one hundredth hospital day. A, The prolapse of the shaggy echo into the right ventricular outflow tract during diastole (white arrow) became more apparent compared with the admission 2DE. B, No abnormal echo was demonstrated either in the main pulmonary artery or the right ventricle during systole.
pulmonary embolism and acute renal failure, but these events were successfully treated. Pulmonic valve replacement was performed on the one hundred eleventh hospital day without preceding cardiac catheterization. A small subaortic ventricular septal defect was repaired with direct suture. Rupture and small vegetations (1 mm in size) of the septal leaflet and small vegetations of the posterior leaflet of the pulmonic valve were present (Fig. 4). The valve was replaced with a St. Jude Medical prosthesis. The patient was discharged in good condition.
Echocardiographic findings of right-sided infective endocarditis with pulmonic valve vegetation have been reported recently. 1-6Initially we thought that this case had pulmonic valve vegetation and that septic emboli were originating from this vegetation. Although the infective process was controlled and embolic episodes ceased, this abnormal shaggy echo in the right ventricular outflow tract during diastole became larger with clinical evidence of increased pulmonic regurgitation. The characteristic finding of this case was that the oscillating shaggy echo was present in the right ventricular outflow tract during
Volume 107 Number 5, Part 1
Brie/Communications
1029
Fig. 4. Rupture of the septal leaflet of the pulmonic valve (white arrow) was found at the level of the pulmonic ring and small vegetations were present on that and the posterior leaflets at surgery.
diastole, but no abnormal echoes were seen in the pulmonary artery or in the right ventricle during systole. These findings persisted until the time of operation, and a ruptured septal leaflet with very small vegetations was found at the time of operation. It was considered that the ruptured pulmonic leaflet was floating in the right ventricle during diastole, but this leaflet was attached closely to the pulmonary arterial wall during systole because of the high velocity of the blood stream. Thus oscillating shaggy echoes seen in the right ventricular outflow tract only during diastole may be a characteristic of ruptured pulmonic valve with or without vegetations.
REFERENCES
1. Kramer NE, Gill SS, Patel R, Towne WD: Pulmonary valve vegetations detected with echocardiography. Am J Cardiol 39:1064, 1977. 2. Dzindzio BS, Meyer L, Osterholm R, Hopeman A, Woltjen J, Forker AD: Isolated gonococcal pulmonary valve endocarditis: Diagnosis by echocardiography. Circulation 59:1319, 1979. 3. Okumachi F, Yoshikawa J, Takatsuka K, Owaki T, Kato H, Yanagihara K, Takagi Y, Shingaki M, Baba K, Tomita Y, Fukaya T, Tatemichi K, Shomura T, Yoshizumi M: Crosssectional echocardiographic diagnosis of pulmonary valve vegetation. J Cardiogr 9:279, 1979. 4. Melvin ET, Berger M, Lutzker LG, Goldberg E, Mildvan D: Noninvasive methods for detection of valve vegetations in infective endocarditis. Am J Cardiol 47:271, 1981. 5. Sharma S, Katdare AD, Munsi SC, Kinare SG: M-mode echographic detection of pulmonic valve infective endocarditis. AM HEARTJ 102:131, 1981. 6. Chiang CW, Lee YS, Chang CH, Hung JS, Chen L: Preoperative and postoperative bchocardiographic studies of pulmonic valvular endocarditis. Chest 80:232, 1981.
Echographic premature pulmonic valve opening: Sign of reduced right ventricular distensibility Fernando Benito, M.D., Jos~ Lopez-Send6n, M.D., Jos~ Oliver, M.D., Miguel A. Garcia-Fernandez, M.D., Isabel Coma-Canella, M.D., and Federico Lomberas, M.D. Madrid, Spain.
Under normal conditions the pulmonic valve is closed during ventricular diastole, opening during systole when right ventricular (RV) pressure exceeds pulmonary artery pressure. Atrial contraction produces a small doming of the pulmonic leaflets that can be appreciated in the M-mode echocardiogram as a posterior deflection of the pulmonic valve. In some circumstances a powerful atrial contraction may cause the pulmonic valve to open. ~Opening of the pulmonic valve before atrial contraction (premature valve opening) has been previously described in situations of RV volume overload, ~,:~ as well as in cases with restriction of diastolic filling to the right heart2, 4 In the present report, the M-mode echocardiographic and hemodynamic findings in 10 patients with premature pulmonic valve opening were studied with special reference to data indicative of reduced RV distensibility. Eight patients were men and two were women; their ages ranged From the Cardiologyand Coronary Care Unit, Department of Internal Medicine, La Paz, Universidad Autonoma. Reprint requests: Fernando Benito, c/ Valderrey 24-6°C, Madrid 29, Spain.