a 50-year - old female presented to pusan national university hospital with a 1-month history of fatigue , loss of weight , and shortness of breath . there was a continuous murmur with thrill over the pulmonary area and a diastolic murmur over the aortic area . computed tomography ( ct ) , pulmonary edema and multiple cavitary lesions , which were surrounded by ground - glass opacity suspecting septic emboli , were observed ( fig . transthoracic and transesophageal echocardiography revealed severe aortic valve regurgitation , with highly mobile masses on the right and the left coronary cusps , which were irregularly thickened and prolapsed . continuous shunt flow , from the descending aorta to the pulmonary artery , was noted ( fig . the defect size was 6 mm , and the amount of shunt flow was too small to measure . pulmonary hypertension was not suspected because the pressure and the morphology of the right ventricle remained normal . other cardiac valves , including the pulmonary valve , were normal , and no other vegetation was observed on the chambers and the great vessels . the patent ductus arteriosus ( pda ) was isolated and identified primarily . cardiopulmonary bypass ( cpb ) was commenced with aortic and bicaval cannulation . with external ligation of the duct , the patient was then cooled to a temperature of 28 , after which the pulmonary artery was opened . unexpected fresh vegetation was found in the pulmonary artery , at the site opposite to the ductal opening ( fig . the pulmonary artery opening of the duct was identified . as the tissue of the ductus all vegetations on the pulmonary artery were debrided and removed , and the defect of pulmonary artery was repaired directly . all infected tissue , including the valve , was resected and replaced with a mechanical prosthetic valve ( fig . after six weeks of penicillin injection , infection was controlled completely , including that in the lung and the spleen . in the 1-year follow - up , no recurrence was observed . the risk of infective endocarditis ( ie ) , with a small pda in adults , appears to be extremely low . , ie occasionally needs surgical treatment . however , there is little experience of surgical treatment . according to the previous reports , open closure with cpb , rather than ligation , was strongly recommended , as a surgical intervention of pda in adults , due to the risk of severe hemorrhage from the fragile ductal tissue . in addition , considering pulmonary embolization from the dislodgement of vegetation and the incomplete elimination of infective foci , complete resection of pda and closure , under direct vision , was strongly suggested . infected emboli are common , and the frequently involved site is the pulmonary arterial wall , opposite to the opening of pda . to suspect the possibility of embolic vegetation on the pulmonary artery is reasonable , even if vegetation is preoperatively noticed only on the left side valve , as in our case . in conclusion , inspection inside of the pulmonary artery is essential for a complete removal of the infected material and for ensuring the safety of closing the pda with endocarditis in adult patients .
a 50-year - old female was admitted to pusan national university hospital with complaints of fatigue and sweating . 
 echocardiography showed a small patent ductus arteriosus ( pda ) and highly mobile vegetations on the aortic valve . 
 emergency operation was performed due to the high risk of embolization and severe aortic regurgitation . 
 when the pulmonary artery opened , we found unexpected fresh vegetation . 
 the tissue of the pda was fragile and infected . 
 we successfully removed the infected tissue , closed the pda with a patch , and replaced the aortic valve with a mechanical prosthesis .