Abstract
A 38y. old woman was admitted to a Cardiology Department due to increased exertional dyspnea and decreased exercise tolerance.
Echocardiography performed in an outpatient setting has found a substantial enlargement of the right ventricle and severe tricuspid regurgitation.
Physical examination
significantly enlarged liver, pulsation of jugular veins and numerous scars in the pits elbow.
ECG
sinus rhythm 85 / min. Right axis deviation. LPH. Hypertrophy of the right atrium. QS in V1-V4.
Transthoracic and Transesophageal Echocardiography (TTE,TEE) EF 64%, a significant increase in a right heart chambers (RVDD 4.1 cm, severe tricuspid regurgitation with completely disappearing of tricuspid valve ( only part of septal leaflet was present, which was a consequence of pressure equalization between the right atrium and the right ventricle). In addition, it revealed the structure connected with the pulmonary valve leaflet and moving between the right ventricular outflow tract and pulmonary trunk (most probably healed vegetation, 1.2 x 0.5 cm ).
Computed tomography (CT) confirmed the significant enlargement of right heart chambers (EDV 335 ml, ESV 143 ml, SV 192 ml, EF ∼ 58%) with displacement of interatrial septum to the left and the flattening of the interventricular septum . Complete destruction of the tricuspid valve leaflets, with the remaining residual part of septal leaflet was observed. The pulmonary valve was connected mobile irregular structure 2,5 cm x 0,5 cm.
Laboratory tests revealed a history of cytomegalovirus infection (p / body IgG> 500,000U / ml). Other tests (HIV, hepatitis B, reaction W-R) - were negative. There was no laboratory and clinical signs of active infection at present.
Patient demanded to be discharged from the hospital and refused operation.
DISCUSSION
Echocardiography did not confirm diagnosis of pulmonary hypertension. D-dimer values of 396 ng / ml (normal <500 ng / ml) excluded suspicion of pulmonary embolism. Left ventricular ejection fraction was normal (EF ∼ 64%), BNP reached the value of 153 pg / ml (normal 0-100pg / ml).
This case deserves attention because it documents severe right heart endocarditis by the person using drugs intravenously with an extremely rare takeover of both right heart valves and septic pulmonary embolism. Despite such a large morphological change in the heart of a patient remains in a relatively good clinical condition (NYHA class II/ III). The observed structure of the pulmonary trunk should be considered as healed vegetation. In the absence of consent to the surgery the patient is still treated pharmacologically.
Abstract P855 Figure. Pic.1
Multimodality imaging in COVID19 patient with large mobile RV thrombus protruding into the pulmonary trunk with bilateral pulmonary embolism
