Infective Pseudoaneurysm of the Anterior Mitral Leaflet Accompanied by Aortic Wall Vegetation

A 46-year-old man with a history of cigarette smoking was referred to our hospital for further evaluation of infective endocarditis. He had a history of fever of 45 days’ duration. Previously in workup for fever, the patient had undergone transthoracic echocardiography, showing vegetations on the aortic and mitral valves, hence his referral to our hospital. On physical examination, he was febrile with no peripheral signs of endocarditis. On cardiac auscultation, a systolic murmur in the apex and a diastolic murmur in the left parasternal border could be heard. Electrocardiography showed sinus tachycardia with poor R-wave progression in V1-V4. Blood cultures were negative probably due to the previous administration of antibiotics. Transthoracic and transesophageal echocardiographic examinations revealed vegetations on the anterior mitral leaflet with pseudoaneurysm formation, which had ruptured to the left ventricle, and moderate to severe mitral regurgitation (Figure 1, Videos 1 & 2). Also, these imaging studies showed destructive aortic valve and large vegetations with severe aortic regurgitation and a highly mobile vegetation on the anterior wall of the aorta, near the right coronary artery (RCA) ostium prolapsing to the proximity of the RCA ostium (Figure 2, Videos 3 & 4). There was no turbulent flow in the ostium of the RCA in color flow Doppler study. The left ventricle was severely enlarged with moderate systolic dysfunction and global hypokinesia. Coronary computed tomography angiography was unremarkable. Finally, mitral and aortic valve replacement was done for the patient, and postoperative antibiotics were continued for 4 weeks. The patient had an uneventful recovery period.