Left atrial endocarditis as a rare complication of mitral valve endocarditis: a clinical case

Abstract

Background: Infective Endocarditis (IE) is considered as a multifaceted problem in every aspect from etiology and presentation to diagnosis and management. Early recognition of this disease and especially its complications, remain a critical task for the cardiologist. Atrial endocarditis is a rare and sometimes unrecognized complication of mitral valve endocarditis.

Case presentation: We present a 48 year-old male patient who was admitted to our clinic because of recent onset of malaise, fever, jaundice and peripheral edema. Important physical findings were peripheral stigmata of IE in addition to holosystolic murmur over the left sternal border. Transthoracic and transesophageal echocardiophy revealed a severe eccentric MR due to a flailed posterior mitral valve caused by IE. The presence of atrial septal endocarditis caused by jet streaming was also observed. Blood culture was positive for streptococcus oralis and antibiotic therapy was immediately initiated. Considering the large burden of infective tissue, the patient was planned for an early surgical intervention. A minimally invasive resection of the atrial mass, direct closure of the defect, resection of the diseased portions of mitral leaflets and implantation of a biological mitral valve prosthesis was performed. Intra-operative and histological findings confirmed provisional diagnosis by echocardiography.

Conclusions: Together with comprehensive echocardiographic evaluation, attention should be placed on mural vegetations and excluded among all cases of mitral valve endocarditis, particularly those with severe eccentric regurgitant jets.

Figure 1

TEE showing the flail Posterior Mitral Leaflet (P2), with associated vegetations and a large regurgitant orifice area.

Figure 2

Three dimensional surgical view of MV, flail P₂and small vegetations.

Figure 3

Bi-caval view in TEE, small aneurysm of IAS is filled a homogenouse sessile mass consistent with jet lesion vegetation (left) and color compare mode to show the eccentric jet of MR and jet lesions on IAS, arrowhead indicates the atrial vegetation (right).

Figure 4

The intraoperative findings with correlated reconstructed 3D TEE image, the asterisk indicate the atrial vegetation, the “footprints” of MV endocarditis.

Figure 5

The intraoperative findings with correlated reconstructed 3D TEE image, the asterisk indicate the atrial vegetation, the “footprints” of MV endocarditis.

Figure 6

Histological findings from the resected atrial septum showing an old focal subendocardial bleeding, a focal mild to moderate fibrosis and some neutrophil granulocytes.