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Address correspondence: Dustin Hang MD, Department of Anesthesiology, Medical College of Wisconsin, 8701 West Watertown Plank Road, Wauwatosa, WI 53226
A 50-YEAR-OLD, 70- kg, 172- cm man with known bicuspid aortic valve disease and severe
aortic insufficiency presented to the authors’ institution with a 3-day history of
“pulsating” chest pain, dyspnea with exertion, and bilateral lower extremity swelling.
The patient previously was hospitalized on several occasions for the treatment of
recurrent Streptococcus cristatus bacteremia originating from poor dentition. He also was receiving apixaban for the
treatment of a cephalic vein thrombosis. The physical examination was notable for
sinus tachycardia (122 beats/min), grade III/VI systolic and diastolic murmurs heard
best at the left sternal border, bilateral lower extremity pitting edema, and red
petechiae on both hands and feet. The patient was anemic (hemoglobin of 8.0 g/dL)
and had renal insufficiency (serum creatinine concentration of 1.66 mg/dL). Leukocytosis
was present (11.8 103/µL). The plasma brain natriuretic peptide level was markedly elevated (20,063 pg/mL).
An increase in high-sensitivity troponin concentration also was observed. An electrocardiogram
revealed sinus tachycardia and low-voltage QRS complexes, but acute ST-segment changes
were absent. Transthoracic echocardiogram revealed vegetations on both the aortic
and mitral valves, resulting in severe regurgitation. Transesophageal echocardiography
(TEE) also was performed as part of the diagnostic evaluation, and the following images
were obtained (Fig. 1-3; Videos 1-3). What is the diagnosis?
Fig 1Midesophageal right ventricular inflow-outflow transesophageal echocardiography view.
Structural remodeling of the left atrial appendage in patients with chronic non-valvular atrial fibrillation: Implications for thrombus formation, systemic embolism, and assessment by transesophageal echocardiography.
Anatomy of the normal left atrial appendage: A quantitative study of age-related changes in 500 autopsy hearts: Implications for echocardiographic examination.
Prevalence of potential risk factors for stroke assessed by transesophageal echocardiography and carotid ultrasonography: The SPARC study. Stroke prevention: Assessment of risk in a community.
