A 31-year old male was admitted with suspected infective endocarditis given intravenous drug use, lung and cerebral abscesses and Staphyloccus aureus bacteraemia. TTE imaging was limited given supine positioning and mechanical ventilation but suggested a posterior mitral valve leaflet (PMVL) mass. Three-dimensional TOE provided uniquely detailed assessment of two complex infective masses. The attachment of the presumed P2 mass on TTE was indeterminant even on 2D-TOE, appearing attached to the PMVL or AMVL depending on rotational view. 3D-TOE imaging and subsequent multiplanar and volumerendered reconstruction revealed this to be a complex, large vegetation attached to the anterior aspect of the anterolateral commissure with mobile heads prolapsing into the left atrium and causing mild mitral regurgitation through a small basal perforation. The second mass was a filamentous vegetation attached to the LVOT, prolapsing towards but not contacting the aortic valve.Comprehensive assessment of complex vegetations is crucial for optimal surgical planning. 3D-TOE allows rapid, accurate, unique assessment of such masses through unlimited multiplanar reconstructions, volume rendered real-time imaging and colour full-volume regurgitation assessment which may not always possible on 2D-TTE or 2D-TOE. 3D imaging should be routinely used in TOE and in particular in suspected endocarditis.
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Muhammad Khan, Ruben DeSousa, Kam Rai and Jamal Nasir Khan
Viren Ahluwalia, Faizel Osman, Jitendra Parmar and Jamal Nasir Khan
Summary
Despite 3D echocardiography (3DE) acquiring significantly greater data than standard 2D echocardiography (2DE), it is underutilised in assessing cardiac anatomy and physiology. A key advantage is the ability of a single 3DE acquisition to be post-processed to generate volume-rendered 3D models and an unlimited number of multiplanar reconstruction (MPR) images. We describe the case of a highly anxious patient with life-threatening complex aortic valve endocarditis and aortic root abscess, refusing transesophageal echocardiography (TOE) under general anaesthesia with tachycardia, breathlessness and acute kidney injury precluding accurate or safe gated (computed tomography) CT, who was comprehensively assessed with a rapid 3D-TOE under sedation. This led to timely surgery and an excellent outcome for the patient.
Learning points:
- 3DE is of greater clinical value than 2DE as it is able to post-process a single 3DE image acquisition into volume rendered 3D models, and provide an unlimited number of multiplanar reconstruction (MPR) images.
- 3DE is highly effective in difficult cases where speed is important.
- 3DE is superior in the planning of complex surgical cases.
