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An 84 year old woman was referred for surgical evaluation. Her clinical history was characterised by hypertension and a permanent pacemaker implanted in June 1997 because of complete atrioventricular block. Two months before, she had undergone successful antibiotic treatment for a gastrointestinal infection; one month after discharge she had septic fever and a new diastolic murmur. Blood cultures were positive forCandida albicans.
Transthoracic echocardiography showed normal cardiac sections and a large mass in the right atrium prolapsing into the tricuspid valve orifice. Transoesophageal echocardiography (pictured) showed two large vegetations: one attached to the pacemaker catheter; the second free in the right atrium and connected to the first vegetation. Both vegetations prolapsed into the tricuspid valve during diastole. There were no signs of pulmonary involvement. The patient did not undergo surgery because her general clinical condition was very compromised and the surgical risk too high.