Comparison of Two-Dimensional and M-Mode Echocardiography In the Evaluation of Patients With Infective Endocarditis
S. MINTZ, MD MORRIS N. KOTLER, MD, FACC BERNARD L. SEGAL, MD, FACC WAYNE R. PARRY
GARY
Philadelphia, Pennsylvania
M-mode and two-dimensional echocardiographic evaluation of infectious endocarditis and its complications was reviewed. in 21 consecutive patients with clinical endocarditis, 22 valves were involved (12 aortic, 5 mitral and 5 tricuspid). M-mode echocardiography detected vegetations in 10 patients (four aortic, two mitral and four tricuspid) and detected complications of endocarditis in 2 patients (one aortic root abscess and one flail aortic cusp). Two-dimensional echocardiography detected vegetations in 9 patients (four aortic, one mitral and four tricuspid) and detected complications in ten patients (five flail aortic cusps, one aortic root abscess, one slnus of Vaisaiva aneurysm, two flail mitral leaflets and one flail tricuspid valve). Thus, although M-mode and two-dimensional echocardiography had a similar ability to detect actual vegetations, two-dimensional echocardiography was superior to M-mode echocardiography in diagnosing complications of the destructive process.
M-mode echocardiography is useful in diagnosing valvular vegetations and in detecting some of the complications of bacterial endocarditis.’ However, it was suggested that M-mode echocardiography will detect vegetations in only approximately 34 percent2 to 55 percent? of patients with bacterial endocarditis. Two explanations for this low sensitivity are possible. First, the diagnostic ability of this technique may be related to vegetation size, and thus M-mode echocardiography may detect only large vegetations. Second, the M-mode technique only visualizes limited areas of the valvular and anular surfaces. Two-dimensional echocardiography is a technique that provides information about the spatial orientation and motion of intracardiac surfaces that are “silent” to M-mode echocardiography. The purpose of this report is to determine the value of two-dimensional’echocardiography in the diagnosis of infective endocarditis and its complications. Methods
Patients: The M-mode and two-dimensional echocardiographic findings in 21 consecutive
From the William Likoff Cardiovascular Institute. Hahnemann Medical College and Hospital, Philadelphia, Pennsylvania. Manuscript received September 19. 1978; revised manuscript received November 9. 1978, accepted November 9, 1978. Address for reprints: Gary S. Mintz, MD, William Likoff Cardiovascular Institute, Hahnemann Medical College, 230 North Broad Street, Philadelphia, Pennsylvania 19102.
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patients with a clinical diagnosis of infective endocarditis were reviewed, All 21 patients were febrile. Twelve patients presented with or developed congestive failure during their hospital stay. All had new regurgitant murmurs of the involved valves. Blood cultures were positive in 18 patients (Table I). Three other patients had culture-negative endocarditis; all three had had antibiotic therapy. Echocardiography: M-mode echocardiographic studies were performed in the supine or left lateral decubitus position using a Smith Kline Ekoline 20A ultrasonoscope with a 2.25 megahertz medium (7.5 cm) internally focused transducer. Permanent recordings were obtained with an Irex 101 Continutrace Recorder. Two-dimensional echocardiographic studies were performed using either a Grumman Health Systems RT-400 cx a Varian V-3000 phased-array sector
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ET AL.
ever, no distinct vegetation was seen. In one patient (Case 8) the posterior aortic wall had a double density, suggesting an aortic root abscess. In five patients (Cases 1, 9, 10, 11 and 12) the aorta and aortic valve were normal. The two-dimensional echocardiographic findings in the 12 patients with aortic valve endocarditis are also listed in Table I. In four patients (Cases 3,4,6 and 7) aortic valve vegetations were identified as rapidly moving high density masses attached to one of the aortic valve cusps (Fig. 2). In four patients the two-dimensional study detected a flail aortic valve cusp (Fig. 3); the M-mode echocardiogram was normal in three of these patients (Cases 1,9 and 12) and also showed a flail cusp in one of them (Case 3). In addition, one patient (Case 7) whose initial study showed a vegetation later had a flail aortic valve cusp. One patient (Case 2) had a thickened, calcified aortic valve without a distinct vegetation or any other evidence of endocarditis. One patient (Case 8) had a double density of the posterior aortic wall, suggesting an aortic root abscess. One patient (Case 5) had an outpouching of the aorta into the right atrium, suggesting a ruptured sinus of Valsalva aneurysm (Fig. 4). The results of t.he studies were nor-
scanner. The illustrations presented here were photographed from single frame videotape images. The limitations of such illustrations include (1) a loss of the visual integration of motion that normally accompanies real-time imaging, and (2) a degradation of image quality caused by photographing a single field of a complete videotape frame that normally consists of two interlaced fields. Complete two-dimensional echocardiographic studies included (1) the long axis view to evaluate the aorta, the aortic valve and the mitral valve, (2) transverse views through the aortic and mitral valves, (3) a sagittal view of the tricuspid valve, and (4) the apical view to evaluate the mitral and tricuspid valves. Surgical or pathologic confirmation was available in 11 patients. Ten patients had successful valve replacement; one patient died before surgery. Statistical analysis was performed with the chi-square method.
Results Aortic valve endocarditis: Twelve patients had a clinical diagnosis of aortic valve endocarditis. The Mmode echocardiographic findings in these patients are listed in Table I. Four patients (Cases 3,4,6 and 7) had an aortic valve vegetation (Fig. 1). In two patients (Cases 2 and 5) the aortic valve appeared sclerotic, the leaflets were thickened, and leaflet motion was reduced; howTABLE I
Bacteriologic, M-mode and Two-dimensional Echocardiographic and Pathologic Data in 18 Patients wlth Infective Endocardftis Patient
Organism
M-Mode Findings
Two-Dimensional Findinos
Patholoaic Data
Aortic Valve Endocarditis
3
Pneumococcus Staph. aureus Pneumococcus
4 5
Strep. viridans Culture negative
6 7’a b
Croup D Strep. H. parainfluenza
:
&oup A Strep Strep. viridans Strep. viridans Staph. aureus Streo. viridans
: IO 11 12
-Flail cusp Valve sclerosis Vegetation, flail cusp Vegetation Sinus of Valsalva aneurysm Vegetation Vegetation Flail cusp Root abscess Flail cusp Normal Normal Flail cuso
Normal Valve sclerosis Vegetation, flail cusp Vegetation Valve sclerosis Vegetation Vegetation Flail cusp Root abscess Normal Normal Normal Normal
Mitral Valve Endocarditis
13 14’
Strep. viridans Staph. aureus
Prolapse, vegetation Normal
Prolapse Ruptured chordae
15
Culture negative
Prolapse
Ruptured chordae
16 17
Strep. viridans Culture negative
Vegetation Normal
Vegetation Normal
14+
Staph. aureus
Ruptured chordae
18*a
Anaerobic gram negative bacillus
Excessive systolic separation Vegetation Normal Vegetation Vegetation Vegetation
Vegetation Vegetation Vegetation Vegetation
Not available Not available Vegetation, flail cusp+ Vegetations Sinus of Valsalva aneurysm, endocarditist Vegetation+ ii& cusps Root abscess5 Flail cusp’ Not available Not available Not available I--
-.---. .-.- -_-_-.___-.-_ Not available Ruptured chordae, endocarditist Ruptured chordae. endocarrfitist Not available Not available
Tricuspid Valve Endocarditis
b :90 21
Multiple organisms Eichinella coodens Staph. aureus
Ruptured chordae, endocarditist
Vegetation Not available Vegetation* Not available Not available
---
Patients 7 and 18 each had two studies: an initial study (a) and a follow-up study (b). + One patient had both mitral and tricuspid endocarditis. t Surgical findings. 5 Autopsy findings. H. = Hemophilus; Staph. = Staphylococcus; Strep. = Streptococcus. l
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FIGURE 1. Case 7. M-mode echocardiogram in a patient with aortic valve endocarditis. The vegetation (dark arrow) is attached to the aortic valve during diastole and also prolapses into the left ventricular outflow tract during diastole (open arrow). Ao = aorta; ECG = electrocardiogram; LA = left atrium; LSB MF = left sternal border medium frequency phonocardiogram; MV = mitral valve.
Diast.
Syst.
FIGURE 2. Case 7. Diastolic (Diast.) and systolic (Syst.) frames of a two-dimensional echocardiographic study from the same patient with sot-tic valve endocarditis. Each frame is accompanied by a labeled, idealized diagram. During diastole, the vegetation (VEG) is attached to the aortic valve. During systole, the valve motion unrestricted, is and the vegetation is no longer seen. The study immediately before surgery only showed a flail cusp. The presence of a flail cusp without a vegetation was confirmed at surgery. A = anterior; Ao = aorta; I = inferior; IVS = interventricular septum: LA = left atrium; LPW = left ventricular posterior wall; MV = mitral valve; P = posterior; S = superior.
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ma1 in two patients (Cases 10 and 11). The long axis view was best for detecting a vegetation, flail cusp or root abscess. The transverse view of the aortic valve was useful in detecting a sinus of Valsalva aneurysm. Anatomic confirmation of these findings was available in seven patients (Table I); three (Cases 3,4 and 6) had vegetations (one with a flail cusp), one (Case 8) had an aortic root abscess, two (Cases 7 and 9) had a flail cusp without a vegetation, and one (Case 5) had a ruptured sinus of Valsalva aneurysm. Mitral valve endocarditis: The M-mode echocardiographic findings in five patients with mitral valve endocarditis are listed in Table I. Two patients (Cases 13 and 15) had mitral valve prolapse with redundancy and thickening of the anterior or posterior leaflet (Fig. 5). One patient (Case 16) had a vegetation. The M-mode studies in the other two patients (Cases 14 and 17) were normal. The two-dimensional echocardiographic findings in these patients are listed in Table I. Two patients (Cases 14 and 15) had a flail anterior mitral leaflet (Fig. 6); there was rapid systolic motion of the leaflet’s tip beyond the line of mitral valve closure into the left atrium. One (Case 15) of these two patients also had a localized increased anterior mitral valve leaflet thickness. One patient (Case 13) had mitral valve prolapse. One patient (Case 16) had an anterior mitral leaflet vegetation; during systole the vegetation curled into the left ventricular outflow tract. The results of one study (Case 17) were normal. The long axis view was best for detecting a vegetation or a flail valve. Surgical observation in two patients confirmed the presence of endocarditis with ruptured chordae tendineae.
ECHOCARDIOGRAPHIC
FIGURE 3. Diastolic frames from two-dimensional studies of two patients with aortic valve endocarditis and flail aortic valve leaflets. Each single frame is accompanied by a labeled, idealized diagram. Panel A, Case 9. This patient had a flail noncoronary cusp (NCC) without a vegetation confirmed at surgery. The organism was Streptococcus viridans. The M-mode echocardiographic findings were normal. Note that the noncoronary cusp hangs below the right coronary cusp (WC) into the left ventricular outflow tract. Panel 6, Case 3. In this patient both a vegetation and a flail noncoronary cusp were confirmed at surgery. The organism was Pneumococcus. The M-mode echocardiogram showed a vegetation prolapsing into the left ventricular outflow tract. Note that the flail noncoronary cusp with an attached vegetation hangs below the right coronary cusp into the left ventricular outflow tract. AML = anterior mitral valve leaflet; other abbreviations as in Figure 2.
valve endocarditis: The M-mode echofindings in five patients with tricuspid valve endocarditis are summarized in Table I. (One patient [Case 141 had both tricuspid valve and mitral valve endocarditis.) In four patients (Cases 18-21) a vegetation was identified (Fig. 7). In the fifth patient (Case 14) the M-mode study disclosed excessive systolic tricuspid valve separation. Tricuspid
cardiographic
FIGURE 4. Case 5. Diastolic (Diast.) and systolic (Syst.) frames from a two-dimensional echocardiographic study of a patient with culture-negative endocarditis and a ruptured sinus of Valsalva aneurysm confirmed at surgery. Each single frame is accompanted by a labeled, ldeallzed dkgram. The aneurysm (An) appears as an outpouching from the aorta (Ao) into tha right atrium (RA). The M-mode echocardiogram only showed a sclerotic aortic valve. ATL = anterior tricuspid leaflet; PTL = posterior tricuspid leaflet; RV = right ventricle; other abbreviations as in Figure 2.
EVALUATION
A
A
I
ET AL
OF ENDOCARDITIS---MINTZ
--IS
S
I
-tP
P
B
The two-dimensional echocardiographic findings in these five patients are summarized in Table I. In four patients (Cases 18-21) a dense mass was attached to the tricuspid valve (Fig. 8). In one of these patients, (Case 18) the results of a subsequent M-mode study were normal, but the two-dimensional study showed a dense mass in the area of the tricuspid valve anuius. In the fifth patient (Case 14), whose M-mode recording re-
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FIGURE 5. Case 15. M-mode echocardiogram from a patient with known mitral valve prolapse in whom infective endocarditis and a flail anterior leaflet mitral (AML) developed. Note the marked holosystolic prolapse and the shaggy appearance of both the anterior and posterior mitral leaflets (PML). Apex-LF = apex-low frequency phonocardiogram; EGG = electrocardiogram; PA-HF = pulmonic area-high frequency phonocardiogram; Resp = respiration.
vealed excessive systolic tricuspid valve separation, flail anterior and posterior tricuspid leaflets were seen. The sagittal view was best for detecting a vegetation or flail leaflets. Surgical confirmation was available in two patients. Both had endocarditis; one also had flail anterior and posterior tricuspid valve leaflets. Discussion M-mode echocardiography: The use of M-mode echocardiography in detecting valvular vegetations was described in 1973.4 The most characteristic M-mode appearance of a vegetation’ is that of a nonuniform
echo-producing mass attached to a valve leaflet with unrestricted and often chaotic valve motion. These echo-producing masses are usually described as “shaggy.” The sensitivity of M-mode echocardiography in detecting valvular vegetations is low; the results are positive in approximately 34 percent2 to 55 percent” of patients with endocarditis. In patients with infective endocarditis and clinical findings of valvular insufficiency, the M-mode echocardiographic findings are more sensitive.” It was suggested that the specificity of these findings is high; however, a recent report6 indicates that features of endocarditis may be seen in most patients with the mitral valve prolapse syndrome.
FIGURE 6. Case 15. Diastolic (Dfft.) and systolic (Syst.) frames from a two-dimensional echocardiogaphic study of the same patient as in Figure 5. Each single frame is accompanied by a labeted, idealized diagram. The study shows a vegetation (VEG) attached to the anterior mitral leaflet and a flail anterior mitral leaflet (AML). During systole, the tip of the anterior mitral leaflet moved past the line of mitral valve closure into the left atrium (LA). These findings were confirmed at surgery. LV = left ventricle; PML = posterior mitral leaflet; other abbreviations as in Figure 2.
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EVALUATION
OF ENDOCARDITIS---MINT2
Syst.
ET AL.
Diast.
FIGURE 8. Case 19. Systolic (Syst.) and diastolic (diast.) frames from a two-dimensional echocardiographic study of the same patient as in Figure 7. Each single frame is accompanied by a labeled, idealized diagram. The study shows a vegetation (VEG) attached to the anterior tricuspid valve leaflet (ATL). When the valve opened in diastole, the vegetation moved with the leaflet into the right ventricle (RV). A vegetation was confirmed at surgery. CT = chordae tendineae; PTL = posterior tricuspid valve leaflet; RA = right atrium.
FIGURE 7. Case 19. M-mode echocardiogram from a patient with tricuspid valve endocarditis. Note the thickened anterior tricuspid leaflet (ATL). The leaflet’s motion was not restricted during diastole. The vegetation is indicated by the arrows.
Myxomas may be confused with vegetations.’ Valve calcification or thickening may also be confused with vegetations; conversely, valve calcification or thickening may obscure the identification of a vegetation. M-mode echocardiography is also useful in diagnosing complications of endocarditis. An aortic root abscess may be suggested by a double density of the aortic wa11.7 The criteria for a flail aortic valve include diastolic aortic valve fluttering with prolapse of the echoes into the left ventricular outflow tract.8 Premature closure of the mitral valve is echocardiographic evidence of the marked hemodynamic derangement of acute aortic insufficiency.g Systolic intracavitary left atria1 echoes, fine systolic mitral valve fluttering, coarse diastolic anterior mitral valve leaflet fluttering, chaotic diastolic posterior leaflet motion and marked holosystolic mitral valve prolapse may suggest ruptured chordae tendineae.‘O Two-dimensional vs. M-mode echocardiography: The two-dimensional features of valvular vegetations were previously described.‘l The lesions appear as rapidly oscillating masses attached to or replacing normal valve tissue. Two-dimensional studies are also useful in detecting ruptured chordae tendineae.‘O Our 21 patients with clinical endocarditis had 22 valves involved. Vegetations were detected in 10 valves with M-mode echocardiography and in 9 valves with two-dimensional echocardiography. Thus, the sensitivity of the two techniques in detecting actual vegetations is similar (approximately 45 percent). In one patient (Case 13) the results of the M-mode study were
positive for a mitral valve vegetation, but the results of the two-dimensional study were negative. Two-dimensional echocardiography was superior to M-mode echocardiography in detecting complications of endocarditis. Complications were detected in 2 patients with M-mode echocardiography and in 10 patients with two-dimensional echocardiography (P
S. MINTZ, MD MORRIS N. KOTLER, MD, FACC BERNARD L. SEGAL, MD, FACC WAYNE R. PARRY
GARY
Philadelphia, Pennsylvania
M-mode and two-dimensional echocardiographic evaluation of infectious endocarditis and its complications was reviewed. in 21 consecutive patients with clinical endocarditis, 22 valves were involved (12 aortic, 5 mitral and 5 tricuspid). M-mode echocardiography detected vegetations in 10 patients (four aortic, two mitral and four tricuspid) and detected complications of endocarditis in 2 patients (one aortic root abscess and one flail aortic cusp). Two-dimensional echocardiography detected vegetations in 9 patients (four aortic, one mitral and four tricuspid) and detected complications in ten patients (five flail aortic cusps, one aortic root abscess, one slnus of Vaisaiva aneurysm, two flail mitral leaflets and one flail tricuspid valve). Thus, although M-mode and two-dimensional echocardiography had a similar ability to detect actual vegetations, two-dimensional echocardiography was superior to M-mode echocardiography in diagnosing complications of the destructive process.
M-mode echocardiography is useful in diagnosing valvular vegetations and in detecting some of the complications of bacterial endocarditis.’ However, it was suggested that M-mode echocardiography will detect vegetations in only approximately 34 percent2 to 55 percent? of patients with bacterial endocarditis. Two explanations for this low sensitivity are possible. First, the diagnostic ability of this technique may be related to vegetation size, and thus M-mode echocardiography may detect only large vegetations. Second, the M-mode technique only visualizes limited areas of the valvular and anular surfaces. Two-dimensional echocardiography is a technique that provides information about the spatial orientation and motion of intracardiac surfaces that are “silent” to M-mode echocardiography. The purpose of this report is to determine the value of two-dimensional’echocardiography in the diagnosis of infective endocarditis and its complications. Methods
Patients: The M-mode and two-dimensional echocardiographic findings in 21 consecutive
From the William Likoff Cardiovascular Institute. Hahnemann Medical College and Hospital, Philadelphia, Pennsylvania. Manuscript received September 19. 1978; revised manuscript received November 9. 1978, accepted November 9, 1978. Address for reprints: Gary S. Mintz, MD, William Likoff Cardiovascular Institute, Hahnemann Medical College, 230 North Broad Street, Philadelphia, Pennsylvania 19102.
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patients with a clinical diagnosis of infective endocarditis were reviewed, All 21 patients were febrile. Twelve patients presented with or developed congestive failure during their hospital stay. All had new regurgitant murmurs of the involved valves. Blood cultures were positive in 18 patients (Table I). Three other patients had culture-negative endocarditis; all three had had antibiotic therapy. Echocardiography: M-mode echocardiographic studies were performed in the supine or left lateral decubitus position using a Smith Kline Ekoline 20A ultrasonoscope with a 2.25 megahertz medium (7.5 cm) internally focused transducer. Permanent recordings were obtained with an Irex 101 Continutrace Recorder. Two-dimensional echocardiographic studies were performed using either a Grumman Health Systems RT-400 cx a Varian V-3000 phased-array sector
Journal of CARDIOLOGY
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ET AL.
ever, no distinct vegetation was seen. In one patient (Case 8) the posterior aortic wall had a double density, suggesting an aortic root abscess. In five patients (Cases 1, 9, 10, 11 and 12) the aorta and aortic valve were normal. The two-dimensional echocardiographic findings in the 12 patients with aortic valve endocarditis are also listed in Table I. In four patients (Cases 3,4,6 and 7) aortic valve vegetations were identified as rapidly moving high density masses attached to one of the aortic valve cusps (Fig. 2). In four patients the two-dimensional study detected a flail aortic valve cusp (Fig. 3); the M-mode echocardiogram was normal in three of these patients (Cases 1,9 and 12) and also showed a flail cusp in one of them (Case 3). In addition, one patient (Case 7) whose initial study showed a vegetation later had a flail aortic valve cusp. One patient (Case 2) had a thickened, calcified aortic valve without a distinct vegetation or any other evidence of endocarditis. One patient (Case 8) had a double density of the posterior aortic wall, suggesting an aortic root abscess. One patient (Case 5) had an outpouching of the aorta into the right atrium, suggesting a ruptured sinus of Valsalva aneurysm (Fig. 4). The results of t.he studies were nor-
scanner. The illustrations presented here were photographed from single frame videotape images. The limitations of such illustrations include (1) a loss of the visual integration of motion that normally accompanies real-time imaging, and (2) a degradation of image quality caused by photographing a single field of a complete videotape frame that normally consists of two interlaced fields. Complete two-dimensional echocardiographic studies included (1) the long axis view to evaluate the aorta, the aortic valve and the mitral valve, (2) transverse views through the aortic and mitral valves, (3) a sagittal view of the tricuspid valve, and (4) the apical view to evaluate the mitral and tricuspid valves. Surgical or pathologic confirmation was available in 11 patients. Ten patients had successful valve replacement; one patient died before surgery. Statistical analysis was performed with the chi-square method.
Results Aortic valve endocarditis: Twelve patients had a clinical diagnosis of aortic valve endocarditis. The Mmode echocardiographic findings in these patients are listed in Table I. Four patients (Cases 3,4,6 and 7) had an aortic valve vegetation (Fig. 1). In two patients (Cases 2 and 5) the aortic valve appeared sclerotic, the leaflets were thickened, and leaflet motion was reduced; howTABLE I
Bacteriologic, M-mode and Two-dimensional Echocardiographic and Pathologic Data in 18 Patients wlth Infective Endocardftis Patient
Organism
M-Mode Findings
Two-Dimensional Findinos
Patholoaic Data
Aortic Valve Endocarditis
3
Pneumococcus Staph. aureus Pneumococcus
4 5
Strep. viridans Culture negative
6 7’a b
Croup D Strep. H. parainfluenza
:
&oup A Strep Strep. viridans Strep. viridans Staph. aureus Streo. viridans
: IO 11 12
-Flail cusp Valve sclerosis Vegetation, flail cusp Vegetation Sinus of Valsalva aneurysm Vegetation Vegetation Flail cusp Root abscess Flail cusp Normal Normal Flail cuso
Normal Valve sclerosis Vegetation, flail cusp Vegetation Valve sclerosis Vegetation Vegetation Flail cusp Root abscess Normal Normal Normal Normal
Mitral Valve Endocarditis
13 14’
Strep. viridans Staph. aureus
Prolapse, vegetation Normal
Prolapse Ruptured chordae
15
Culture negative
Prolapse
Ruptured chordae
16 17
Strep. viridans Culture negative
Vegetation Normal
Vegetation Normal
14+
Staph. aureus
Ruptured chordae
18*a
Anaerobic gram negative bacillus
Excessive systolic separation Vegetation Normal Vegetation Vegetation Vegetation
Vegetation Vegetation Vegetation Vegetation
Not available Not available Vegetation, flail cusp+ Vegetations Sinus of Valsalva aneurysm, endocarditist Vegetation+ ii& cusps Root abscess5 Flail cusp’ Not available Not available Not available I--
-.---. .-.- -_-_-.___-.-_ Not available Ruptured chordae, endocarditist Ruptured chordae. endocarrfitist Not available Not available
Tricuspid Valve Endocarditis
b :90 21
Multiple organisms Eichinella coodens Staph. aureus
Ruptured chordae, endocarditist
Vegetation Not available Vegetation* Not available Not available
---
Patients 7 and 18 each had two studies: an initial study (a) and a follow-up study (b). + One patient had both mitral and tricuspid endocarditis. t Surgical findings. 5 Autopsy findings. H. = Hemophilus; Staph. = Staphylococcus; Strep. = Streptococcus. l
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FIGURE 1. Case 7. M-mode echocardiogram in a patient with aortic valve endocarditis. The vegetation (dark arrow) is attached to the aortic valve during diastole and also prolapses into the left ventricular outflow tract during diastole (open arrow). Ao = aorta; ECG = electrocardiogram; LA = left atrium; LSB MF = left sternal border medium frequency phonocardiogram; MV = mitral valve.
Diast.
Syst.
FIGURE 2. Case 7. Diastolic (Diast.) and systolic (Syst.) frames of a two-dimensional echocardiographic study from the same patient with sot-tic valve endocarditis. Each frame is accompanied by a labeled, idealized diagram. During diastole, the vegetation (VEG) is attached to the aortic valve. During systole, the valve motion unrestricted, is and the vegetation is no longer seen. The study immediately before surgery only showed a flail cusp. The presence of a flail cusp without a vegetation was confirmed at surgery. A = anterior; Ao = aorta; I = inferior; IVS = interventricular septum: LA = left atrium; LPW = left ventricular posterior wall; MV = mitral valve; P = posterior; S = superior.
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ma1 in two patients (Cases 10 and 11). The long axis view was best for detecting a vegetation, flail cusp or root abscess. The transverse view of the aortic valve was useful in detecting a sinus of Valsalva aneurysm. Anatomic confirmation of these findings was available in seven patients (Table I); three (Cases 3,4 and 6) had vegetations (one with a flail cusp), one (Case 8) had an aortic root abscess, two (Cases 7 and 9) had a flail cusp without a vegetation, and one (Case 5) had a ruptured sinus of Valsalva aneurysm. Mitral valve endocarditis: The M-mode echocardiographic findings in five patients with mitral valve endocarditis are listed in Table I. Two patients (Cases 13 and 15) had mitral valve prolapse with redundancy and thickening of the anterior or posterior leaflet (Fig. 5). One patient (Case 16) had a vegetation. The M-mode studies in the other two patients (Cases 14 and 17) were normal. The two-dimensional echocardiographic findings in these patients are listed in Table I. Two patients (Cases 14 and 15) had a flail anterior mitral leaflet (Fig. 6); there was rapid systolic motion of the leaflet’s tip beyond the line of mitral valve closure into the left atrium. One (Case 15) of these two patients also had a localized increased anterior mitral valve leaflet thickness. One patient (Case 13) had mitral valve prolapse. One patient (Case 16) had an anterior mitral leaflet vegetation; during systole the vegetation curled into the left ventricular outflow tract. The results of one study (Case 17) were normal. The long axis view was best for detecting a vegetation or a flail valve. Surgical observation in two patients confirmed the presence of endocarditis with ruptured chordae tendineae.
ECHOCARDIOGRAPHIC
FIGURE 3. Diastolic frames from two-dimensional studies of two patients with aortic valve endocarditis and flail aortic valve leaflets. Each single frame is accompanied by a labeled, idealized diagram. Panel A, Case 9. This patient had a flail noncoronary cusp (NCC) without a vegetation confirmed at surgery. The organism was Streptococcus viridans. The M-mode echocardiographic findings were normal. Note that the noncoronary cusp hangs below the right coronary cusp (WC) into the left ventricular outflow tract. Panel 6, Case 3. In this patient both a vegetation and a flail noncoronary cusp were confirmed at surgery. The organism was Pneumococcus. The M-mode echocardiogram showed a vegetation prolapsing into the left ventricular outflow tract. Note that the flail noncoronary cusp with an attached vegetation hangs below the right coronary cusp into the left ventricular outflow tract. AML = anterior mitral valve leaflet; other abbreviations as in Figure 2.
valve endocarditis: The M-mode echofindings in five patients with tricuspid valve endocarditis are summarized in Table I. (One patient [Case 141 had both tricuspid valve and mitral valve endocarditis.) In four patients (Cases 18-21) a vegetation was identified (Fig. 7). In the fifth patient (Case 14) the M-mode study disclosed excessive systolic tricuspid valve separation. Tricuspid
cardiographic
FIGURE 4. Case 5. Diastolic (Diast.) and systolic (Syst.) frames from a two-dimensional echocardiographic study of a patient with culture-negative endocarditis and a ruptured sinus of Valsalva aneurysm confirmed at surgery. Each single frame is accompanted by a labeled, ldeallzed dkgram. The aneurysm (An) appears as an outpouching from the aorta (Ao) into tha right atrium (RA). The M-mode echocardiogram only showed a sclerotic aortic valve. ATL = anterior tricuspid leaflet; PTL = posterior tricuspid leaflet; RV = right ventricle; other abbreviations as in Figure 2.
EVALUATION
A
A
I
ET AL
OF ENDOCARDITIS---MINTZ
--IS
S
I
-tP
P
B
The two-dimensional echocardiographic findings in these five patients are summarized in Table I. In four patients (Cases 18-21) a dense mass was attached to the tricuspid valve (Fig. 8). In one of these patients, (Case 18) the results of a subsequent M-mode study were normal, but the two-dimensional study showed a dense mass in the area of the tricuspid valve anuius. In the fifth patient (Case 14), whose M-mode recording re-
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FIGURE 5. Case 15. M-mode echocardiogram from a patient with known mitral valve prolapse in whom infective endocarditis and a flail anterior leaflet mitral (AML) developed. Note the marked holosystolic prolapse and the shaggy appearance of both the anterior and posterior mitral leaflets (PML). Apex-LF = apex-low frequency phonocardiogram; EGG = electrocardiogram; PA-HF = pulmonic area-high frequency phonocardiogram; Resp = respiration.
vealed excessive systolic tricuspid valve separation, flail anterior and posterior tricuspid leaflets were seen. The sagittal view was best for detecting a vegetation or flail leaflets. Surgical confirmation was available in two patients. Both had endocarditis; one also had flail anterior and posterior tricuspid valve leaflets. Discussion M-mode echocardiography: The use of M-mode echocardiography in detecting valvular vegetations was described in 1973.4 The most characteristic M-mode appearance of a vegetation’ is that of a nonuniform
echo-producing mass attached to a valve leaflet with unrestricted and often chaotic valve motion. These echo-producing masses are usually described as “shaggy.” The sensitivity of M-mode echocardiography in detecting valvular vegetations is low; the results are positive in approximately 34 percent2 to 55 percent” of patients with endocarditis. In patients with infective endocarditis and clinical findings of valvular insufficiency, the M-mode echocardiographic findings are more sensitive.” It was suggested that the specificity of these findings is high; however, a recent report6 indicates that features of endocarditis may be seen in most patients with the mitral valve prolapse syndrome.
FIGURE 6. Case 15. Diastolic (Dfft.) and systolic (Syst.) frames from a two-dimensional echocardiogaphic study of the same patient as in Figure 5. Each single frame is accompanied by a labeted, idealized diagram. The study shows a vegetation (VEG) attached to the anterior mitral leaflet and a flail anterior mitral leaflet (AML). During systole, the tip of the anterior mitral leaflet moved past the line of mitral valve closure into the left atrium (LA). These findings were confirmed at surgery. LV = left ventricle; PML = posterior mitral leaflet; other abbreviations as in Figure 2.
742
April 1979
The American Journal of CARDIOLOGY
Volume 43
ECHOCARDIOGRAPHIC
EVALUATION
OF ENDOCARDITIS---MINT2
Syst.
ET AL.
Diast.
FIGURE 8. Case 19. Systolic (Syst.) and diastolic (diast.) frames from a two-dimensional echocardiographic study of the same patient as in Figure 7. Each single frame is accompanied by a labeled, idealized diagram. The study shows a vegetation (VEG) attached to the anterior tricuspid valve leaflet (ATL). When the valve opened in diastole, the vegetation moved with the leaflet into the right ventricle (RV). A vegetation was confirmed at surgery. CT = chordae tendineae; PTL = posterior tricuspid valve leaflet; RA = right atrium.
FIGURE 7. Case 19. M-mode echocardiogram from a patient with tricuspid valve endocarditis. Note the thickened anterior tricuspid leaflet (ATL). The leaflet’s motion was not restricted during diastole. The vegetation is indicated by the arrows.
Myxomas may be confused with vegetations.’ Valve calcification or thickening may also be confused with vegetations; conversely, valve calcification or thickening may obscure the identification of a vegetation. M-mode echocardiography is also useful in diagnosing complications of endocarditis. An aortic root abscess may be suggested by a double density of the aortic wa11.7 The criteria for a flail aortic valve include diastolic aortic valve fluttering with prolapse of the echoes into the left ventricular outflow tract.8 Premature closure of the mitral valve is echocardiographic evidence of the marked hemodynamic derangement of acute aortic insufficiency.g Systolic intracavitary left atria1 echoes, fine systolic mitral valve fluttering, coarse diastolic anterior mitral valve leaflet fluttering, chaotic diastolic posterior leaflet motion and marked holosystolic mitral valve prolapse may suggest ruptured chordae tendineae.‘O Two-dimensional vs. M-mode echocardiography: The two-dimensional features of valvular vegetations were previously described.‘l The lesions appear as rapidly oscillating masses attached to or replacing normal valve tissue. Two-dimensional studies are also useful in detecting ruptured chordae tendineae.‘O Our 21 patients with clinical endocarditis had 22 valves involved. Vegetations were detected in 10 valves with M-mode echocardiography and in 9 valves with two-dimensional echocardiography. Thus, the sensitivity of the two techniques in detecting actual vegetations is similar (approximately 45 percent). In one patient (Case 13) the results of the M-mode study were
positive for a mitral valve vegetation, but the results of the two-dimensional study were negative. Two-dimensional echocardiography was superior to M-mode echocardiography in detecting complications of endocarditis. Complications were detected in 2 patients with M-mode echocardiography and in 10 patients with two-dimensional echocardiography (P
