Echocardiographic diagnosis of isolated pulmonary valve endocarditis.

Abstract

SUMMARY A patient is described in whom diagnosis of isolated pulmonary valve endocarditis was made by M-mode and two dimensional echocardiography. Angiography confirmed the presence of vegetations on the pulmonary valve. At cardiac surgery a quadricuspid, non-stenotic valve with ruptured medial leaflet covered by necrotic vegetations and a small ventricular septal defect were found.Echocardiography is known to be useful in diagnosing valvular endocarditisl 2 of the mitral and aortic valves but only two cases of pulmonary valve endocarditis have been previously diagnosed in this way. We report another. Case reportA 46-year-old man, known to have an undiagnosed asymptomatic congenital heart defect, had a high temperature in November 1979. He was treated with antibiotics which were at first effective but pyrexia reappeared two weeks later. Cephalosporin was given intravenously for 10 days, but the patient became very weak, and haemorrhagic purpura appeared on the legs; evening pyrexia persisted. Finally, in May 1980, he was admitted to this hospital; bacterial endocarditis was suspected and penicillin started.At physical examination the patient appeared very ill and febrile, with gross hepatosplenomegaly. A grade 4/6 harsh pansystolic murmur was heard in the second and the third left intercostal space followed by a grade 1/6 diastolic murmur. The second heart sound was almost inaudible on the pulmonary area.The electrocardiogram and chest x-ray film appeared to be within normal limits. The M-mode echocardiogram ( Fig. 1) Treatment with cefuroxime led to a brief remission of fever with apparent clinical improvement but high fever reappeared after 10 days despite continuous treatment and finally the patient developed a left lower lobe infarction with pleural effusion. As he was so ill, cardiac catheterisation and angiocardiography, previously planned, were abandoned and cardiac surgery was performed on the evidence of the echocardiographic diagnosis on 5 June. The pulmonary artery was incised transversely above the level of the valve. A quadricuspid non-stenotic valve was seen; the medial leaflet was ruptured and covered by an overgrowth of necrotic tissue (Fig. 3); a small ventricular septal defect was found just below the pulmonary valve which was excised. A biological prosthesis was inserted, and the ventricular septal defect sutured with four stitches on Teflon pledgets.Culture of the valve grew Staphylococcus cutis.

Quadricuspid Pulmonary Valve: Case Report and the Comparison with Quadricuspid Aortic Valve

“…[ 5 ] demonstrated that QPV typically persists in normal function throughout the lifetime. However, pulmonary valve replacement [ 70 , 73 , 86 , 87 ] or pulmonary valvuloplasty [ 71 , 74 ] for QPV regurgitation have been reported. The Ross surgery for the congenital anomaly of the pulmonic valve is unfavorable [ 62 ].…”

“…To the best of our knowledge, only 2 cases of QPV with infective endocarditis were reported. 1 patient with a ventricular septal defect and no stenotic QPV was detected at autopsy [ 70 ]. Additionally, 1 of 13 patients with congenital heart disease and with right-sided infectious endocarditis revealed an isolated QPV [ 92 ].…”

Echocardiographic demonstration of pulmonary valve endocarditis associated with congenital ventricular septal defect.

“…There is, however, a report of the echocardiographic diagnosis of pulmonary endocarditis where a small ventricular septal defect was subsequently shown at operation. 18 Subacute bacterial endocarditis must be diagnosed on clinical and bacteriological grounds, but echocardiography is valuable in detecting associated valve lesions. Modem echocardiographic machines can detect vegetations with diameters of > 2-3 mm.…”