Eustachian Valve Endocarditis

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Bowers J, Krimsky W, Gradon JD. The pitfalls of transthoracic echocardiography. A case of eustachian valve endocarditis. Tex Heart Inst J 2001;28(1):57-9

A case of infective endocarditis involving the vestigial eustachian valve is presented and the available English medical literature is reviewed. Only 5 prior cases have been reported: 4 of those required transesophageal echocardiography for diagnosis, and the other was found at autopsy. This clinical entity is routinely missed on transthoracic echocardiography. Injection drug use is a common predisposing factor, and Staphylococcus aureus is the most commonly identified organism. This report broadens the differential diagnosis of endovascular infections in injection drug users and highlights the importance of transesophageal echocardiography for diagnosis in selected patients.

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San Roman JA, Vilacosta I, Sarria C, Garcimartin I, Rollan MJ, Fernandez-Aviles F. Eustachian valve endocarditis: Is it worth searching for? Am Heart J 2001 Dec;142(6):1037-40

BACKGROUND: Only a few cases of eustachian valve endocarditis have been reported. Whether the eustachian valve is an uncommon site for a vegetation to be attached or whether the disease is missed because a systematic approach to this valve is not routinely performed in the search for vegetations is not known. METHODS: Every patient suspected of having endocarditis undergoes a specific approach, which includes a systematic study of the eustachian valve. In 10 patients with large valves but without signs and symptoms of endocarditis, we identified 2 specific findings: width <3 mm and a regular oscillating movement. A blinded evaluation in the 10 control subjects and 30 patients with right-sided endocarditis, including the 5 with eustachian valve endocarditis, showed an agreement of 97% (39/40). RESULTS: Five of 152 patients with right-sided endocarditis were found to have eustachian valve vegetations (3.3%). Patients were young (age range 22-34 years) and all had predisposing factors (3 intravenous drug abusers, 2 central venous lines), fever, and septic pulmonary embolism. Staphylococcus aureus was cultured in all cases. Tricuspid involvement was found in 4 patients, and only 1 patient had isolated eustachian valve endocarditis. All patients did well with culture-guided antibiotics. CONCLUSIONS: Our results suggest that eustachian valve endocarditis may be more frequent than is believed. Thus a systematic interrogation of the eustachian valve should be included in the echocardiographic examination of a patient suspected of having endocarditis.

Sawhney N, Palakodeti V, Raisinghani A, Rickman LS, DeMaria AN, Blanchard DG. Eustachian valve endocarditis: a case series and analysis of the literature. J Am Soc Echocardiogr 2001 Nov;14(11):1139-42

Eustachian valve endocarditis (EVE) is a syndrome characterized by clinical signs and symptoms of right-sided infective endocarditis in association with an infective vegetation on the eustachian valve. EVE usually occurs without associated involvement of any other cardiac valves, and it is difficult to diagnose accurately by transthoracic echocardiography. Transesophageal echocardiography appears to be a more sensitive tool for the diagnosis of EVE, and it is recommended when a patient with typical signs of right-sided endocarditis has normal results on a transthoracic echocardiography study. In general, EVE responds well to conventional antibiotic therapy.

Schmidt MA, Nigbor D, Eitzman DT. Eustachian valve endocarditis caused by Streptococcus viridans. J Am Soc Echocardiogr 2001 Oct;14(10):1042-3

A 76-year-old man was admitted for ethanol detoxification. He was found to be in atrial fibrillation with a rapid ventricular response that was refractory to electrical and chemical cardioversion attempts. The patient subsequently developed respiratory distress. A transesophageal echocardiogram revealed a vegetation attached to the eustachian valve and blood cultures grew Streptococcus viridans. After treatment with appropriate antibiotics, the patient converted to sinus rhythm with sotalol hydrochloride, and the eustachian valve vegetation resolved. This is the first reported case of eustachian valve endocarditis caused by S viridans.

Punzo F, Guarini P, De Michele M, Accadia M, Irace L, Caruso A, Granato Corigliano G. Eustachian Valve Endocarditis in an Elderly Woman. Echocardiography 1999 Apr;16(3):259-261

The authors describe the transesophageal echocardiographic findings in Eustachian valve endocarditis for a 73-year-old woman with a previous history of mitral valve disease. After a 4-week treatment with antibiotics, follow-up echocardiographic examination showed a smaller vegetation.

Eustachian valve endocarditis diagnosed by transoesophageal echocardiography. James PR, Dawson D, Hardman SM. Heart 1999 Jan;81(1):91

Palakodeti V, Keen WD Jr, Rickman LS, Blanchard DG. Eustachian valve endocarditis: detection with multiplane transesophageal echocardiography. Clin Cardiol 1997 Jun;20(6):579-80

Right-sided involvement is fairly common in infective endocarditis, but involvement of the eustachian valve is distinctly rare. The authors present the case of a 36-year-old intravenous drug user with staphylococcal bacteremia and septic pulmonary emboli. Transthoracic echocardiography was normal, but transesophageal echocardiography revealed a large eustachian valve vegetation. This case illustrates the utility of multiplane transesophageal echocardiography in the evaluation of eustachian valve pathology.

Navarro V, Martinez-Alfaro E, Sanz P, Solera J. Eustachian valve endocarditis produced by Staphylococcus hominis in a patient with HIV infection. Rev Clin Esp 1996 Aug;196(8):572-3

Georgeson R, Liu M, Bansal RC. Transesophageal echocardiographic diagnosis of eustachian valve endocarditis. J Am Soc Echocardiogr 1996 Mar-Apr;9(2):206-8

A 33-year-old man with a history of intravenous drug abuse was seen with fever, septic pulmonary embolization, and Staphylococcus aureus bacteremia. Transthoracic echocardiography was nondiagnostic. Transesophageal echocardiography showed a large, pedunculated, and highly mobile vegetation attached to the eustachian valve.

Vilacosta I, San Roman JA, Roca V. Eustachian valve endocarditis. Br Heart J 1990 Nov;64(5):340-1

M mode and cross sectional echocardiography showed a highly mobile globular pedunculated mass(3.0 cm long with a maximum diameter of 1.5 cm) attached to the eustachian valve in a heroin addict with staphylococcal endocarditis.

Edwards AD, Vickers MA, Morgan CJ. Infective endocarditis affecting the eustachian valve. Br Heart J 1986 Dec;56(6):561-2

A previously fit 44 year old man presented with acute staphylococcal pneumonia. Despite appropriate antibiotics he showed signs of continuing sepsis and eventually died. At necropsy endocarditis of the eustachian valve was found.

Marx GR, Bierman FZ, Matthews E, Williams R. Two-dimensional echocardiographic diagnosis of intracardiac masses in infancy. J Am Coll Cardiol 1984 Mar;3(3):827-32

Intracardiac masses in infancy are uncommon. Tumors, thrombi and vegetations of bacterial endocarditis are exceedingly rare in this age group. These masses are seldom diagnosed before the infant's death. In a review of two-dimensional echocardiograms performed from May 1979 to January 1981 on 741 infants less than 2 years of age, intracardiac masses were prospectively identified in 6 patients. All six patients presented with unexplained murmurs associated with either hemodynamic instability, arrhythmias or systemic emboli. One patient had a vegetation from bacterial endocarditis, one had an intracardiac thrombus associated with myocarditis, three had rhabdomyomas (two patients with tuberous sclerosis) and one had a fibro-fatty nodule attached to the eustachian valve. Two-dimensional echocardiography not only was important in the diagnosis, but also provided guidance in the medical and surgical treatment of these patients.

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