PMC5353404_01
Transthoracic echocardiogram in the acute phase. Four apical chamber section. Single large vegetation with echogenicity similar to that of the myocardium and with a small area of attachment to the atrial side of the lateral mitral valve annulus. This mass showed a rapid oscillatory movement, prolapsing into the inflow tract of the left ventricle, clearly distinct from the normal pattern of valve movement. The result was a massive mitral regurgitation due to a perforation in the posterior leaflet, in a native mitral valve with fibrocalcific degeneration
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F1
Pattern of pulsed wave-Tissue Doppler Imaging (PW-TDI) recorded at the level of the endocardial vegetation in the acute phase. Four apical chamber section. The vegetation exhibited a pattern of incoherent motion: an oscillatory movement, rapid and independent from the surrounding tissue, not related to the cardiac cycle. It was measured a peak antegrade velocity of 38.5 cm/s, about four times higher than that obtained at the lateral mitral annulus
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F2
Furthermore, PW-TDI precisely characterized the vegetation mobility, by measuring a peak antegrade velocity of 38.5 cm/s [Figure 2], almost four times higher than the one obtained placing the sample volume at the level of the lateral mitral valve annulus.
Brain magnetic resonance imaging (MRI). Axial diffusion-weighted imaging (DWI) MRI sequences. In the context of a chronic vascular disease, multiple and bilateral hyperintense lesions, suggestive of a cardioembolism
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F3
Transthoracic echocardiogram performed after 2 weeks of intravenous antifungal therapy with fluconazole, in addition to antibiotic therapy with vancomycin and ceftriaxone. Four apical chamber section. Reduction in the size and increased echogenicity of endocardial vegetation, partially calcified, pedunculated, and no longer prolapsing into the inflow tract of the left ventricle
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F4
Pattern of PW-TDI obtained at the level of the mass after 2 weeks of intravenous antifungal therapy with fluconazole, in addition to antibiotic therapy with vancomycin and ceftriaxone. Significant reduction in motility of the vegetation (peak antegrade velocity of 6 cm/s)
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F5