Download Mitral Valve Vegetation

Mitral Valve Vegetation
A 44 year-old woman came in for a 2D Echo and M Mode Doppler to rule out a
vegetation. She was 165 cm tall and weighed 47.20 kg so her BSA was 1.5 m squared.
She had a blood pressure of 119/69 mmHg.
2D
RV
IVS
LV
LVPW
Normal D
0.7-2.3cm
0.6-1.1cm
3.3-5.5cm
0.6-1.1cm
Normal D
LA
2.0-3.7cm
AOR 3.6cm 2.0-3.7cm
LVOT
1.5-2.0cm
RVOT
2.2-3.0cm
M-mode
Diastole
RV
2.4cm
IVS
1.3cm
LV
5.3cm
LVPW 1.2cm
LA
Systole
3.5cm
0.0cm
3.78cm
Diastole
LAD
AOR
3.6cm
LV EF 62.0%
MV
Mn Grad
P1/2T
MV Area
MV DT
MV Planim
E Vmax
A Vmax
E/A
MV VTI
1.25m/s
0.66m/s
1.88
MR PISA R
TV
TR Vmax
TR Pk Grad
RA Pressure
RVSP
TV VTI
2.72m/s
29.6mmHg
10mmHg
39.6mmHg
Left Ventricle: Has an estimated EF of 50 to 55%.
Right Ventricle: Is normal.
Left Atrium: Is considered to be mildly dilated.
Right Atrium: Is mildly dialted.
Aortic Valve: Is trileaflet and normal.
Mitral Valve: Moderate mitral annular calcification. Mild mitral valve regurgitation.
Tricuspid Valve: Is normal in structure. Mild tricuspid regurgitation. The estimated
right ventricular systolic pressure is borderline elevated.
Summary:
1. The left ventricle has an estimated EF of 50-55%.
2. Moderate concentric left ventricular hypertrophy.
3. Right atrium is mildly dilated.
4. Borderline elevated PA systolic pressure.
5. Mild tricuspid regurgitation.
6. The aortic valve is trileaflet and normal.
7. The left atrium is mildly dilated.
8. Mild mitral valve regurgitation.
9. Mobile vegetation on the mitral valve.
10. Moderate mitral annular calcification.
11. No pericardial effusion.
Endocarditis is a cause of vegetations on the heart valves. Endocarditis is exudative
and proliferative inflammatory alterations of the endocardium, characterized by the
presence of vegetations on the surface of the endocardium or in the endocardium itself,
and most commonly involving a heart valve, but also affecting the inner lining of the
cardiac chambers or the endocardium elsewhere. Lesions on the valves may interfere
with the ejection of blood from the heart by causing insufficiency or stenosis of the
valves. Murmurs associated with the heart sounds are the major manifestation and if
interference with the blood flow is sufficiently severe congestive heart failure develops.
The further hazard with endocarditis, especially if it is bacterial in origin, is that of septic
emboli in the lungs or in the other organs.
Altered blood flow around the valves is a risk factor in obtaining endocarditis. The
valves may be damaged congenitally, from surgery, by auto-immune mechanisms, or
simply as a consequence of old age. The damaged part of a heart valve becomes covered
with a blood clot, a condition known as non-bacterial thrombotic endocarditis (NBTE).
In a healthy individual, a bacteremia (where bacteria get into the blood stream through
a minor cut or wound) would normally be cleared quickly with no adverse consequences.
If a heart valve is damaged and covered with a piece of a blood clot, the valve provides a
place for the bacteria to attach themselves and an infection can be established.
The bacteremia is often caused by dental procedures, such as a cleaning or extraction
of a tooth. It is important that a dentist or a dental hygienist is told of any heart problems
before commencing. Antibiotics are administered to patients with certain heart conditions
as a precaution.
Another group of causes result from a high number of bacteria getting into the
bloodstream. Colorectal cancer, serious urinary tract infections, and IV drug use can all
introduce large numbers of bacteria. With a large number of bacteria, even a normal heart
valve may be infected. A more virulent organism (such as Staphylococcus aureus is
usually responsible for infecting a normal valve.
Intravenous drug users tend to get their right heart valves infected because the veins
that are injected enter the right side of the heart. The injured valve is most commonly
affected when there is a pre-existing disease. (In rheumatic heart disease this is the aortic
and the mitral valves, on the left side of the heart.)
Clinical and pathological features include:

Fever, i.e. fever of unknown origin (often spiking caused by septic emboli)

Continuous presence of micro-organisms in the bloodstream determined by serial
collection of blood cultures

Vegetations on valves on echocardiography, which sometimes can cause a new or
changing heart murmur, particularly murmurs suggestive of valvular regurgitation

Vascular phenomena: Septic emboli (causing thromboembolic problems such as
stroke in the parietal lobe of the brain or gangrene of fingers), Janeway lesions
(painless hemorrhagic cutaneous lesions on the palms and soles), intracranial
hemorrhage, conjunctival hemorrhage, splinter haemorrhages

Immunologic phenomena: Glomerulonephritis, Osler's nodes (painful
subcutaneous lesions in the distal fingers), Roth's spots on the retina, positive
serum rheumatoid factor.
The transthoracic echocardiogram has a sensitivity and specificity of
approximately 65% and 95% if the echocardiographer believes there is 'probabable' or
'almost certain' evidence of endocarditis.
Treatment includes high dose antibiotics are administered by the intravenous
route to maximize diffusion of antibiotic molecules into vegetation(s) from the blood
filling the chambers of the heart. This is necessary because neither the heart valves
nor the vegetations adherent to them are supplied by blood vessels. Antibiotics are
continued for a long time, typically two to six weeks. Specific drug regimens differ
depending on the classification of the endocarditis as acute or subacute (acute
necessitating treating for Staphylococcus aureus with oxacillin or vancomycin in
addition to gram-negative coverage). Fungal endocarditis requires specific anti-fungal
treatment, such as amphotericin B.
Surgical removal of the valve is necessary in patients who fail to clear microorganisms from their blood in response to antibiotic therapy, or in patients who
develop cardiac failure resulting from destruction of a valve by infection. A removed
valve is usually replaced with an artificial valve which may either be mechanical
(metallic) or obtained from an animal such as a pig; the latter are termed bioprosthetic
valves.