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Address reprint requests to Karsten Bartels, MD, Assistant Professor of Anesthesiology, Department of Anesthesiology,12401 E. 17th Avenue, Leprino Office Building, 7th Floor, MS B-113, Aurora, CO 80045.
A 50−60-YEAR-OLD MAN with ongoing alcohol and methamphetamine abuse and a suspected
history of intravenous drug use presented to the emergency department with a 1-month
history of bilateral leg pain. Physical examination was significant for a cold left
foot and absent left dorsalis pedis and tibialis posterior pulses. Auscultation revealed
a 4/6 crescendo-decrescendo systolic murmur heard loudest over the right upper sternal
boarder, and a 3/6 diastolic decrescendo murmur heard loudest over the right lower
sternal boarder. Computed tomography angiography confirmed severe bilateral lower
extremity peripheral vascular disease. Following tracheal intubation for progressive
congestive heart failure, transthoracic echocardiography (TTE) revealed moderate aortic
regurgitation and a mass on the aortic valve suggestive of vegetation. The patient
went to the operating room for emergent bilateral embolectomies and fasciotomies.
Subsequently, he underwent tissue aortic valve replacement with patch reconstruction
of aortomitral fibrosa. Intraoperative transesophageal echocardiography (TEE) findings
are shown in Figure 1A-D and corresponding TEE clips are available online (Video 1 A-D).
Fig 1Intraoperative transesophageal echocardiography (TEE) images before and after aortic
valve replacement with patch reconstruction of aortomitral fibrosa. (A) Midesophageal
aortic valve long-axis view showing extensive vegetations and entry to a large aortomitral
abscess cavity (red arrow). (B) Midesophageal aortic valve long-axis view with color-flow
Doppler showing aortic regurgitation. (C) From the perspective of the ascending aorta,
a three-dimensional TEE depicts an en face view of the aortic valve. A large vegetation
(red arrow) extends into the ascending aorta. (D) Midesophageal aortic valve long-axis
view following tissue aortic valve replacement with patch reconstruction of aortomitral
fibrosa.
Reassessment of the phylogenetic position of the bacterium associated with Whippleʼs disease and determination of the 16S-23S ribosomal intergenic spacer sequence.
2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
