PMC10435280_01
Two-dimensional transesophageal echocardiography in different views, illustrating irregularly thickened and destructed bicuspid aortic valve (non-coronary cusp and right coronary cusp fusion) with partially ruptured left coronary cusp (white arrow) and a few small mobile vegetative particles, suggestive of aortic valve involvement and destruction by infective endocarditis (A,B), heralding severe aortic insufficiency (C,D). Moreover, it shows the dilated left main coronary artery (red arrow) with turbulent blood flow inside (E,F).
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F1
A brain CT scan without contrast was suggestive of a non-hemorrhagic stroke involving the left cerebellum (Supplementary Figure S1). TTE and TEE) were performed for better assessment, which revealed an irregularly thickened and destructed bicuspid aortic valve (fusion of non-coronary and right coronary cusps), a few small mobile vegetative lesions, and a partially ruptured left coronary cusp of the aorta, resulting in severe aortic regurgitation (Figure 1). The patient had no aortic ectasia or dilation in view of bicuspid aortic valve or any evidence of endarteritis elsewhere.
Two-dimensional transesophageal echocardiography showing an irregular thickening over the atrial side of the base of anterior mitral valve leaflet (white arrow) (A) suggestive of the involvement of the mitral valve by infective endocarditis, which caused severe mitral regurgitation, demonstrated in color Doppler flow study (red arrow) (B).
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F2
IE involvement of the mitral valve in the base of the anterior leaflet, adjacent to the aortic valve, with severe mitral regurgitation was also evident (Figure 2). The vegetative lesions on both aortic and mitral valves raised the suspicion of a probable simultaneous coronary artery involvement by IE (Figures 2, 3). The algorithmic process of diagnosis in the presented case is provided in Supplementary Figure S2.
Three-dimensional transesophageal echocardiography showing mitral valve endocarditis with irregular thickening over the atrial side of the base of anterior mitral valve leaflet (white arrow) (A) and irregularly thickened and destructed bicuspid aortic valve involved by infective endocarditis (red arrow) (B).
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F3
The vegetative lesions on both aortic and mitral valves raised the suspicion of a probable simultaneous coronary artery involvement by IE (Figures 2, 3). Histopathological evaluation of the excised valves and surrounding tissues confirmed valvular destruction, inflammation, and infection with gram-positive cocci (Supplementary Figure S3).
Contrast-enhanced chest computed tomography scan, showing normal caliber right coronary artery (3 mm) (A), and dilated left main coronary artery (12.7 mm); zoom out (B), and zoom in (C).
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F4
Contrast-enhanced chest multidetector CT scan performed showed aneurysmal dilatation of the left main coronary artery (12.7 mm diameter) with an irregular border, originating from the left coronary sinus extending to the proximal LAD artery, suggestive of CAMA (Figure 4). Figure S4). For all diagnostic tests and selection of therapeutic procedures, the patient was informed about the risks and benefits and signed the written informed consent.