Asian Cardiovasc Thorac Ann 2007;15:455-456
© 2007 Asia Publishing EXchange Ltd
IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY |
Subaortic Valvular Vegetation Mimicking Severe Aortic Valve Stenosis
Delawer Reber, MD,
Paschalis Tossios, MD,
Markus Fritz, MD,
Marlene Helwing, MD1,
Alfried Germing, MD2,
Axel Laczkovics, MD
Department of Cardiothoracic Surgery
1 Institute for Pathology
2 Department of Cardiology, Bergmannsheil, Ruhr University Hospital Bochum, Bochum, Germany
For reprint information contact: Delawer Reber, MD, Tel: 49 234 302 3600, Fax: 49 234 302 6010, Email: delawer.reber{at}ruhr-uni-bochum.de, Department of Cardiothoracic Surgery, Bergmannsheil, Ruhr University Hospital, Bochum, Buerkle-de-la-Camp-Platz-1, 44789 Bochum, Germany.
A 47-year-old male patient with symptoms of severe heart failure was diagnosed with aortic stenosis. Echocardiography showed normal systolic left ventricular function and an aortic valve with a peak transvalvular pressure gradient of 85 mm Hg and a valve area of 0.8 cm2. Cardiac catheterization showed a systolic pressure gradient of 101 mm Hg over the valve (area 0.54 cm2). Thus, the stenotic lesion of the aortic valve was considered to be severe. Prior to planned aortic valve replacement coronary angiography was performed which was normal. There was no history of sepsis preoperatively.
Surgery was performed using extracorporeal circulation under mild hypothermia. During prima vista surgical exploration, trileaflet aortic valve was normal. The leaflets were not thickened, fused or calcified. However, a mass was found below the aortic valve closing the left ventricular outflow tract and somewhat attached to the aortic valve. The mass could be completely removed and the aortic valve was replaced with a bileaflet prosthetic mechanical heart valve. The postoperative re-evaluation and inspection of the preoperative left ventriculogram lastly confirmed the subaortic mass (Figure 1
) mimicking severe aortic valve stenosis. Histology showed a vegetation with masses of bacteria and cellular detritus and granulocytes (Figure 2). The postoperative course was uneventful. He was treated with wide spectrum antibiotic for 6 weeks postoperatively. The patient was discharged home without complications. On three-month follow-up, the patient was asymptomatic. Echocardiography shows intact prosthetic heart valve with normal left ventricular function and dimensions.
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Figure 1. Preoperative left ventriculography with right (A) and left anterior oblique (B) projection of the heart. Note the mass (arrows) protruding in the ascending aorta. In retrospect, this subaortic mass was mimicking severe aortic valve stenosis. Ao asc = ascending aorta; LV = left ventricle.
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Figure 2. Histology: A. The mass had fibrinoid necrosis with marginal demarcation consisting of cellular detritus and granulocytes (arrow) indicating thrombulcerative endocarditis (Hematoxylin and Eosin staining); B. It showed fibrinoid necrosis including bacteria (arrow).
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