LAUSR

A 30-year-old man with a history of fever, systolic murmur over the apex and NYHA III heart failure symptoms was evaluated for suspected endocarditis. Transthoracic echocardiography (TTE) revealed severe mitral valve (MV) regurgitation (volume 100ml, effective orifice area 0.8 cm) with two distinct jets, confirmed by systolic flow reversal in the pulmonary veins and high-velocity transmitral flow (1.4 m/s). Transoesophageal echocardiogram (TEE) corroborated multifaceted destruction of MV with triple signs of endocarditis: a destroyed flail posterior leaflet causing eccentric, severe jet, and an anterior leaflet inflammatory aneurysm with round perforation passing another severe regurgitant jet (see Figure 1(A,B,D)). Three-dimensional (3D) en face view from TEE clearly localised the crater-like perforation within a bulge corresponding to an anterior leaflet inflammatory aneurysm of 10mm diameter (panel C). Antibiotics were administered prior to mitral valve replacement with mechanical bileaflet prosthesis ATS 33 and 3D TEE defined pathomorphology was fully confirmed. Enterococus faecalis was detected in excised material. Our observation is concordant with studies underlining distinct advantages of 3D TEE in the diagnosis of destructive lesions caused by endocarditis. Full assessment of valve morphology and regurgitation was possible exclusively during 3D TEE because of spatial reconstruction of leaflets in surgical views. Thus, 3D echocardiography proved successful in depicting Carpentier’s triad in a single 3D picture explaining aetiology, lesions and mechanism which were thereafter confirmed during surgery. Severe destruction and the young age of the patient tipped the balance toward mitral valve replacement with mechanical prosthesis.