PMC10098003_01
Still-frame images of the mitral and pulmonary valves on TTE (A-D) and TEE (E-H). (A,B) TTE apical four-chamber and parasternal long axis views revealed a well-circumscribed, sessile mass with heterogeneous echotexture which was firmly attached to the atrial side of the posterior leaflet of the mitral valve (white arrow). The mitral valve leaflets were thickened. (E) The maximum diameter of the mass was measured using 2D Xplane imaging at the mid-esophageal level. (G) From the left atrial perspective (en-face view), the vegetation was seen attached to the atrial side of the P2 and P3 portions of the posterior leaflet (white arrow) with 3-dimensional zoom-mode. (C,F) mild-to-moderate central mitral regurgitation was seen on both TTE and TEE with color Doppler. (D,H) The pulmonary valve as visualized on the parasternal short-axis and mid-esophageal right ventricle inflow-outflow view was unremarkable (asterisk). Annotations: LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle; Ao, Aorta; PA, pulmonary artery.
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F1
To further elucidate the nature of the mass and rule out possible thrombi, 2-dimensional and 3-dimensional transesophageal echocardiography (TEE) was subsequently performed (Figures 1E-H).
Evaluation of the mitral and pulmonary valve vegetations using cardiac computed tomography (CT) and cardiac magnetic resonance (CMR). (A,C) CT 2-chamber view and cine-CMR still image in end-systole showing a non-homogeneous, isodense mass involving the posterior leaflet of the mitral valve. (B) CT short axis view of the mitral valve from a basal short axis slice demonstrated the attachment of the vegetation to the P2 and P3 portions of the posterior mitral leaflet. The mitral valve was seen from a left ventricular perspective. (D,E) Transverse CT and CMR images through the right ventricular outflow tract showed a small oscillating mass on the anterior cusp of the pulmonary valve. (F) The myocardium showed no late gadolinium enhancement. (G,H) Normal findings on native-T1 and T2-weighted mapping images. Annotations: LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle; Ao, Aorta.
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LVEF (60.5%) and no regional wall motion abnormalities. Late gadolinium enhancement (LGE) images, native-T1 map, T2 map, and extracellular volume (ECV) map were normal (Figures 2C-H). Electrocardiogram-gated cardiac computed tomography (CT) with multiplanar reconstruction was subsequently performed to better delineate the exact dimensions of the vegetations (Figures 2A,B).
Computed tomography pulmonary angiogram (A) and brain magnetic resonance imaging scan (B,C). (A) No large pulmonary emboli on CTPA. (B,C) Axial FLAIR image showed bilateral hyperintense white matter lesions in the frontal lobes. The number of lesions is more than expected for the patient's age. Annotations: Ao, aorta; RPA, right pulmonary artery; LPA, left pulmonary artery.
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CT angiography. CT of the abdomen and the pulmonary vasculature was negative for emboli (Figure 3A) and possible neoplasms. Deep bilateral white matter hyperintensities (WMH), which were more extensive than expected for the patient's age, were found on her brain magnetic resonance imaging (MRI) scan (Figures 3B,C).
Timeline of patient clinical course.
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F4
TTEs are planned every 1-2 years. The timeline of the patient clinical course is shown in Figure 4.