AORTIC VEGETATIVE PERFORATION OF THE MITRAL-VALVE - A NEW MECHANISM FOR SPREAD OF ENDOCARDITIS

We report the case of a man presenting with a stroke and new heart mur murs 6 weeks after surgery for a malignancy of the colon and urosepsis with blood cultures positive for Streptococcus sanguis. A small echog enic density and a central jet of aortic insufficiency were the only s ignificant findings on transthoracic echocardiographic examination. Tr ansesophageal echocardiography disclosed a filamentous vegetation of t he left coronary cusp of the aortic valve, which penetrated through a fenestration of the anterior leaflet of the mitral valve. Spread of en docarditis from aortic to mitral valves has been explained by burrowin g of infection through the intervalvular fossa and by seeding of the m itral valve by a regurgitant jet from the incompetent aortic valve. Th is is the first report of spread of endocarditis by repeated direct co ntact and erosion of the mitral valve by a prolapsing aortic vegetatio n. This case supports the use of transesophageal echocardiography to i nspect completely the mitral valve in the setting of endocarditis of t he aortic valve and to evaluate the aortic valve when endocarditis of the mitral valve is suspected.