A 56 year old accountant presented with a 3 month history of worsening breathlessness, fever, anorexia, and weight loss. He had no past medical history of note. On examination he was tachycardic with a pulse rate of 120 beats per minute, in overt left ventricular failure with a grade II early diastolic murmur at the left sternal edge and a grade IV pansystolic murmur at the cardiac apex radiating to the axilla. Clubbing of his toes was noted. The erythrocyte sedimentation rate (ESR) was 52 mm/hour. His haemoglobin was 9.3 g/dl. Three blood cultures grew streptococcus sanguis.

A transoesophageal echocardiogram revealed a 15×5 mm mobile, prolapsing vegetation arising from the non-coronary cusp of the aortic valve with associated severe aortic regurgitation. In addition, a hole was seen at the point of contact between the prolapsing vegetation and the mid body of the anterior mitral valve leaflet, resulting in significant mitral regurgitation. He was treated with ampicillin and gentamicin.

The aortic valve was replaced with a bi-leaflet prosthesis. An attempt was made to suture the anterior leaflet of the mitral valve; however, a second more distal perforation was noted, which was not amenable to repair. Therefore, the valve was replaced with a bi-leaflet prosthesis.

Secondary involvement of the anterior mitral valve leaflet due to direct contact with a prolapsing aortic valve vegetation is a rare but recognised complication of aortic valve endocarditis. Most commonly, spread is either direct or due to turbulent jet effects. These images clearly demonstrate the “kissing” vegetation.

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