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Ann Thorac Surg 1996;62:944-945
© 1996 The Society of Thoracic Surgeons
Service de Medecine Interne et Cardiologie, Hôpital de la Conception, 147 Blvd Baille, F13385 Marseille Cedex 5, France
To the Editor:
Infective endocarditis is a rare but very serious complication after cardiac valve replacement. In the majority of cases, diagnosis of such a complication is provided by echocardiography. We report the case of a patient with pseudoinfective endocarditis caused by retention of chordae tendineae.
A 75-year-old patient underwent surgical mitral valve replacement 2 years ago for degenerative mitral insufficiency with disabling dyspnea on exertion. A Carpentier-Edwards bioprosthesis was implanted. He received long-term fluindione (Procter & Gamble, Cincinnati, OH) therapy of 20 mg/day. He was admitted to the hospital after a car crash and underwent right nephrectomy because of a voluminous kidney hematoma. During his hospital stay, a chronic fever developed with blood cultures persistently positive for Streptococcus faecalis. A first abdominal computed tomographic study demonstrated no abnormality. Transesophageal echocardiography with Advanced Technology Laboratory (Bothell, WA) UM9 and a 5-MHz single-plane probe demonstrated a double mobile mass attached to the ventricular aspect of the bioprosthesis (Figs 1, 2
). This mass was mobile on bidimensional examination with a vibratile aspect on time-motion examination (Fig 3), suggesting a possible vegetation. There was no regurgitation or stenosis on Doppler examination of the Carpentier-Edwards mitral valve. The bioprosthesis leaflets were normal. Because of persistent fever with intravenous cefotaxime and gentamicin perfusion, consideration of a cardiac operation was required, in spite of the unusual site of the vegetation. The hypothesis of retention of all chordae tendineae mimicking vegetation was confirmed when a new abdominal computed tomographic study demonstrated a right kidney abscess, with fever disappearance after abscess excision.
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Department of Cardiothoracic Surgery, Columbia-Presbyterian Medical Center, Milstein Hospital, 177 Fort Washington Ave, New York Ny 10032
To the Editor:
This letter by Malaterre and Sunda, which documents the ability of retained chordae tendineae to mimic infected endocarditis, is a valuable contribution to the literature. We have also observed this phenomenon as we routinely preserve both anterior and posterior leaflet chordae. Malaterre and Sunda note that the chordae attached to the papillary muscle may mimic vegetations; however, it is extremely uncommon for vegetations to arise directly from the papillary muscles, and for this reason we usually feel more comfortable that indeed these are residual from the chordal preservation. On the other hand, chordae attached to the valve annulus that are redundant or flat may mimic vegetations and be more difficult to differentiate from an infected endocarditis picture.
We have found that routine intraoperative echocardiography is able to document the presence of these chordae immediately after the valve replacement and can be used as a baseline study with which future evaluations can be compared. In this way, the error of mistakenly diagnosing infected endocarditis can in part be avoided.
University of Massachusetts Medical Center, 55 Lake Ave N, Worcester Ma 01655-0304
To the Editor:
We concur with the point made by Drs Malaterre and Sunda. The echocardiograms accompanying their report show clearly the retained mitral chordae tendineae. We, too, have noted the same echo-dense structure below the mitral prosthesis when all chordae have been retained. The echo density has the appearance expected from retained chordae: thin and mobile.
This finding could in fact be mistaken for a subvalvular tumor or endocarditis vegetation. By the echocardiographer being aware of the likely presence of retained chordae and their appearance, the possibility of mistaking them for a pathologic process should be diminished. A transesophageal echocardiogram obtained intraoperatively after valve implantation will also prove helpful in serving as a baseline study with which future echocardiograms may be compared.
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