PMC4644062_01
Abscess pocket over the left atrium
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F1
A transthoracic echocardiogram (TTE) delineated destruction of mitral and aortic valves by multiple vegetation and multiple small and large aortic ring abscesses extended to surrounding tissue and perforated to right atrium, main pulmonary artery and formation a pocket over the left atrial roof (Figure 1 (Fig. 1), Figure 2 (Fig. 2)).
Multiple abscesses in periannular ring
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F2
A transthoracic echocardiogram (TTE) delineated destruction of mitral and aortic valves by multiple vegetation and multiple small and large aortic ring abscesses extended to surrounding tissue and perforated to right atrium, main pulmonary artery and formation a pocket over the left atrial roof (Figure 1 (Fig. 1), Figure 2 (Fig. 2)).
Destruction of three leaflets of aortic valve
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F3
Further, intra-operative inspection of right atrium showed small vegetations in crater of fistula entrance to right atrium in antero-medial region of tricuspid ring (Figure 3 (Fig. 3)).
Vegetation on destructive anterior mitral leaflet (black arrow)
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F4
Intra-aortic root inspection revealed a defect in non-aortic coronary sinus filled with necrotic materials and an abscess that perforated through the area above the tricuspid valve (Figure 4 (Fig. 4)).
Vegetation in entrance of fistula tract to right atrium in tip of suction (black arrow)
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F5
There was also a fistula between the left-coronary sinus, just near the left coronary ostium to the main pulmonary artery (Figure 5 (Fig. 5)).
Right atrial fistula from non-coronary aortic sinus (black arrow)
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F6
Further intra-operative perception of aortic root revealed a pocket filled by abscess through a defect in left coronary sinus just located over the roof of the left atrium (Figure 6 (Fig. 6)).
Fistula to pulmonary artery (black arrow)
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F7
In addition to the aforementioned fistulas, multiple vegetations were observed on both mitral and aortic valves that caused severe destruction of both valves causing grave regurgitation (Figure 7 (Fig. 7)).
Left coronary defect imposing as a fistula to the left atrial roof (vertical arrow); cardioplegia catheter positioned at the left osmium (horizontal arrow)
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F8
It apeared that mitral valve vegetations were caused by regurgitated aortic valve flow that impinged on aorto-mitral fibrous continuity and subsequently caused the penetration and destruction of the native mitral valve (Figure 8 (Fig. 8)).