a 43-year - old woman , with no significant previous medical history , was admitted due to fever , chills , and headache which she had been experiencing for the past several days .
her laboratory work showed a cell count of 20 /l with 38% neutrophils on cerebrospinal fluid analysis , and elevated levels of serum troponin i ( 11.59 ng / ml ) and creatine kinase - mb ( 17.6 ng / ml ) .
her transthoracic echocardiography ( tte ) showed severe rheumatic aortic stenosis ( as ) with mild aortic regurgitation ( ar ) and a normal left ventricular ( lv ) systolic function .
we needed a complete tee for further evaluation , but the patient refused the examination .
eventually , a diagnosis of infective endocarditis was made via tte finding with clinical correlation .
when the patient was admitted , an antibiotic therapy was performed for the control of infection .
brain magnetic resonance imaging showed multiple embolic infarctions in the frontal , parietal lobe and left corpus callosum .
after 5 days of antibiotic treatment under the suspicion of ie , subsequent atrial flutter and acute pulmonary edema developed .
serum troponin i ( 48.14 ng / ml ) and creatine kinase - mb ( 81.3 ng / ml ) were elevated more compared to the results at the admission . an emergent aortic valvuloplasty was decided .
intraoperative tee examination confirmed severe as and relatively fresh 1.5 cm vegetation on lcc of the av with frequent diastolic prolapse into the aortic root ( fig .
2 ) , but it did not cause cardiac failure ; the ejection fraction ( ef ) was 55 % by modified simpson 's method .
tee showed the vegetation to be in good position across the av ( video 1 and 2 ) .
the surgeon confirmed the state of av as severe commissural fusion , severe thickening with relatively fresh 1.5 cm vegetation , and left coronary ostium partial occlusion by the vegetation .
the patient was weaned from cpb without any hemodynamic instability or changes in st segment on electrocardiography ( ecg ) .
the patient 's cardiac output was 4.0 - 5.4 l / min and cardiac index was 2.3 - 3.1 l / min / m , and there was no change in st segment of 12-lead ecg immediately after the operation in the intensive care unit .
the cardiologist confirmed well - functioning of prosthetic mechanical av and akinesia of apical cap with normal lv ef ( 59% ) via tte .
nonetheless , the anesthesiologist should consider the possibility of coronary compression due to periannular aortic valve abscess and pseudoaneurysms , and coronary embolism or obstruction of the coronary ostium due to the vegetation , to be able to make the diagnosis using tee when the patients with ie present acute hemodynamic disturbance , sign of acs , or myocardial ischemia .
the patient in this study could have been diagnosed as acs , because of the angina , high serum troponin i ( 48.14 ng / ml ) , and creatine kinase - mb ( 81.3 ng / ml ) occurring during the early phase . however , there was no evidence of rwma in the intraoperative tee .
we assumed that the vegetation prolapsed into the left coconary ostium , and that it induced a partial occlusion of the left coronary ostium and a spontaneous escape of the vegetation from the ostium .
the major echocardiographic findings for the diagnosis of ie are vegetation , abscess , and new dehiscence of prosthetic valve .
the vegetation is the most important lesion for the diagnosis of ie , and an oscillating mass attached to valvular structure is a typical characteristic of vegetation .
another major echocardiographic finding for endocarditis is the perivalvular abscess , which is presented by reduced echo density without color flow detected inside .
the patient was diagnosed as ie due to presence of the oscillating vegetation on av , but there was no abscess formation .
vegetation may cause direct occlusion of the coronary artery , especially in the case of av vegetation .
the anesthesiologist should check both the left and right coronary ostia via midesophageal ( me ) short - axis view of the aortic valve , and the right coronary ostium via an me long - axis view .
if the vegetation is large ( > 10 mm ) and movable or fragile , it can increase the incidence of embolism .
another cause of coronary embolism is lv mural thrombi which can be seen in a spontaneous echo contrast .
spontaneous echo contrast is definitive sign of slackened blood flow which is considered as a prothrombotic condition .
a thrombus shows well - defined margins and discrete echo dense mass throughout systole and diastole .
echocardiographic contrast perfusion imaging may be useful in confirming the vascularity of cardiac masses and in differentiating the vascular tumors from benign tumors and thrombi . in the rare cases of myocardial ischemia associated with coronary obstruction due to the vegetation in ie patients ,
echocardiographic findings may present a new rwma , although there was no rwma in our case .
the tee is helpful for finding the etiology in the patient with ie , who is presented with acs , and the management of the complication can be different according to the mechanisms . furthermore , the intraoperative tee could present the unknown or new lesions that were not discovered by the preoperative tte , although the new findings from tee may not affect the method of the operation .
midesophageal short - axis view of aortic valve . relatively fresh 1.5 cm vegetation on the left coronary cusp of the aortic valve
is prolapsing into the left coronary ostium during diastole and partially occluded left coronary ostium .
unfortunately , the video clip associated with the disturbance of the coronary circulation was not recorded , but there is no evidence for obstruction of coronary circulation or left ventricular wall motion abnormality .
la ; left atrium , ra ; right atrium , lco ; left coronary ostium .
midesophageal long - axis view of aortic valve . as noted in the still image , the vegetation attached on the left coronary cusp of the aortic valve is frequently prolapsing into the aortic root during diastole .
lv ; left ventricle , lcc ; left coronary cusp , rcc ; right coronary cusp .
 a 43-year - old woman was admitted due to fever , chills , and headache for several days and was diagnosed as infective endocarditis . 
 intraoperative transesophageal echocardiography ( tee ) examination confirmed severe aortic stenosis and showed relatively fresh 1.5 cm vegetation on the left coronary cusp of the aortic valve ( av ) with frequent diastolic prolapse into the aortic root . 
 this mobile vegetation partially occluded left coronary ostium , but it did not cause cardiac failure . 
 tee showed the vegetation to be in good position across the av . 
 the av replacement with removal of vegetation and mitral valvuloplasty were performed . 
 the patient was weaned from cardiopulmonary bypass without any hemodynamic instability or changes in st segment on electrocardiography . 
 she was discharged on the 28th postoperative day without any complication . 
Case Report
Discussion
Supplementary Materials