Diagnosing Infective Endocarditis by Emergency Department Echocardiogram

A 59-year-old man with a history of a congenital coronary artery sinus fistula presented to the emergency department (ED) after an enlarged cardiac silhouette was noted on a preoperative screening chest x-ray (Figure 1). He was scheduled for an open repair of the lesion. Two months prior, he underwent an unsuccessful attempt at a percutaneous closure of his anomaly. His chest x-ray at that time had been normal (Figure 2).

Figure 1.  Newly enlarged cardiac silhouette 2 months after percutaneous procedure.

Figure 2.  Normal chest x-ray 2 months prior to presentation.

The patient complained of worsening dyspnea, lower extremity edema, a nonproductive cough, and night sweats. He denied fever, chills, and chest pain. Vital signs were remarkable only for mild tachycardia and hypotension. He had crackles, jugular venous distension, moderate bilateral lower extremity edema, and a III/VI systolic murmur.

The emergency medicine resident performed a bedside echocardiogram (Video Clip S1, available as supporting information in the online version of this paper) and noted a severely dilated left ventricle with a depressed ejection fraction. The aortic valve appeared to be abnormally thickened and was prolapsing into the left ventricle, a finding that raised the suspicion for endocarditis (Figure 3). A cardiology consultation confirmed this to be a vegetation with severe aortic insufficiency. Antibiotics were started and he was admitted to the cardiac intensive care unit. He subsequently underwent aortic valve replacement. His ED blood cultures grew coagulase-negative Staphylococcus in five of six bottles.

Figure 3.  Still image from the ED echocardiogram. Ao = aortic outflow tract; AoV = aortic valve; LA = left atrium; LV = left ventricle; PE = pericardial effusion; RV = right ventricle.