Order Pathologic Masses on the Valves

Order Pathologic Masses on the Valves
Order Pathologic Masses on the Valves
1. You are reading a transthoracic echocardiogram on a
28-year-old intravenous drug user with Staphylococcus
aureus bacteremia. Which of the following ultrasound features best describes a typical bacterial vegetation?
A. Irregular shaped, highly mobile oscillating mass on
upstream side of the valve, with independent motion
B. Smooth, highly mobile spherical mass on the tips of the
valve leaets
C. Thin, lamentous strands, attached to the upstream side
of the valve
D. Mobile, sessile mass, with broader base, noncontrast
enhancing, attached to the upstream side of the valve
2. You are asked to evaluate a 34-year-old young male
who presented with Streptococcus viridans bacteremia.
His transthoracic echocardiography is shown in Video 41.1.
He was started on ceftriaxone, pending the results of culture susceptibilities.
Which of the following is the next best step in management?
A. Recommend transesophageal echocardiography to
con rm the diagnosis.
Order Pathologic Masses on the Valves
B. Continue treatment with ceftriaxone while pending
susceptibility and switch to culture-sensitive antibiotics
with a total duration of therapy with 6 weeks.
C. Continue treatment with ceftriaxone for 6 weeks and
perform TEE as recommended.
D. Repeat TTE in few days to document resolution.
E. Surgical consultation.
3. A 68-year-old male with coronary artery bypass surgery,
diabetes, and HTN presented with recurrent TIA-like
symptoms. His symptoms resolved by the time he arrived
to the ER. His physical exam was unremarkable including
neurologic exam. His prior workup (CT scan, carotid duplex,
TTE) revealed mild atherosclerosis of the left common
carotid artery and grade II atheroma in the aorta, and his
ASA dose was increased to 325 mg daily. Due to recurrence of
TIA, he underwent TEE, and images are shown in Video 41.2.
What is the next best course of action?
A. Add warfarin to his ASA therapy
B. Surgical consultation
C. Draw blood cultures and initiate broad-spectrum antibiotics
D. Reassurance and no further workup needed
4. A patient presents with Streptococcus bovis bacteremia and
a small vegetation (6 mm) on the anterior mitral leaet. On
further investigation, it is discovered that he was recently
diagnosed with colon cancer, underwent partial colectomy
and now on chemotherapy. He is started on i.v. nafcillin
and gentamicin. You are asked to perform a transesophageal echocardiogram. What is the diagnostic accuracy
(sensitivity) of transthoracic and transesophageal echocardiography, respectively, in detecting valvular vegetations?
(Select the best response.)
Order Pathologic Masses on the Valves
A. 90%
C. 60% to 80% and 80% to 90%
D. <40% and <90%
5. In keeping with the current recommendations, prophylaxis
for infective endocarditis is not recommended in which of
the following patients? (Review echocardiography images
for each clinical presentation listed.)
Chapter 41
Pathologic Masses
on the Valves
Mikel D. Smith and Kunal Bodiwala
Figure 41.1
(c) 2015 Wolters Kluwer. All Rights Reserved.
Chapter 41 Pathologic Masses on the Valves 333
Figure 41.3 (Continued)
A. A 28-year-old female with congenital repair of VSD,
undergoing restorative dental procedure (Video 41.3 and
Fig. 41.1)
B. A 38-year-old male with corrective surgery for tetralogy
of Fallot with RVOT conduit with bioprosthetic PV,
undergoing bronchoscopy with biopsy (Video 41.4)
C. A 45-year-old male with bicuspid aortic valve who
is undergoing mechanical aortic valve replacement
(Video 41.5)
D. A 65-year-old female with mitral valve prolapse who is
undergoing coronary artery bypass graft surgery for threevessel coronary artery disease (Video 41.6 and Fig. 41.2)
E. A 57-year-old male who underwent cardiac transplant
2 years ago and on chronic immunosuppressive therapy,
who is undergoing root canal surgery (Video 41.7)
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