• Images in cardiology

One of the major applications of echocardiography is to identify vegetations in patients with suspected endocarditis. A 60 year old woman with sinus venosus atrial septal defect (ASD) presented with history of prolonged fever and dyspnoea. Before admission she was treated with several antibiotics, but without resolution of fever. Since the clinical suspicion of endocarditis was high a transthoracic echocardiogram was performed, which showed a large echodense mass on the pulmonic valve suggestive of vegetation (below left). Also noted was dilatation of the right sided cardiac chambers and pulmonary artery, and severe tricuspid and moderate pulmonary regurgitation suggestive of severe pulmonary hypertension. A transoesophageal echocardiogram confirmed these findings (below right) and revealed a large sinus venosus ASD with left to right shunt. Blood cultures remained negative, however, and the patient was treated empirically with intravenous antibiotics. The hospital course was complicated by respiratory failure and pneumonia. Despite aggressive medical management the patient died in the hospital after a prolonged stay.

Isolated native pulmonary valve endocarditis is rare, accounting for 1.5–2.0% of all admissions for endocarditis. Intravenous drug abuse, alcoholism, sepsis, and catheter related infections account for the majority of predisposing factors. Between 1960 and 2000 only 38 cases have been reported in the literature in structurally normal valves. Intravenous antibiotics remain the primary mode of treatment, and indications for valve replacement are the same as for other valves.