48 year old man with persistent Staph aureus bacteraemia…

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TTE PLAX – The overall LV and RV systolic function appears normal with a small pericardial effusion. There are no valvular masses apparent here. However, look closely beneath the PMVL. There appears to be an echogenic density that is obscuring the inferior lateral wall. More views required?

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TTE PSAX – the echogenic mass is seen here in the short axis view at the level of the mitral valve in the lateral wall.

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TTE A4C – there’s no denying that there is a large echogenic mass abutting the lateral wall of the LV. It is well circumscribed with mixed echogenecity (as opposed to cystic looking).

A TOE was performed to better define the lesion.

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TOE MO 0′ 4C – the large mass is seen adjacent to the inferior lateral wall. The mitral valve appears normal.

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TOE MO 0′ LV – By rotating the TOE probe towards the left, it is apparent that the mass is not within the ventricular wall. The mass still appears of mixed echogenecity.

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TOE MO 2C

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TOE MO 4C CFD – There is blood flow through the mass lesion.

SO?

Have you have been looking closely at the valves for vegetations? Were you looking for fistulae, regurgitation?

Or none of the above?

This patient actually had a mycotic aneurysm in the antero-lateral wall of the LV. This was resected surgically. Not convinced? Have a look at the loops again!