Thoracoabdominal CT Angiography Detection of Anterior Mitral Leaflet Perforation in Recurrent Infective Endocarditis After Serial Echocardiograms: A Case Report.

Infective endocarditis (IE) can cause destructive valvular complications, including leaflet perforation and vegetation. Echocardiography remains the primary imaging modality for valvular assessment; however, computed tomography angiography (CTA) may reveal clinically important cardiac findings when performed for other urgent indications. We report the case of a 70-year-old male with recurrent IE, prior prosthetic aortic valve endocarditis first diagnosed in 2022, multiple aortic valve and aortic root operations, thoracic endovascular aortic repair with a left subclavian stent, prior aortic graft infection, methicillin-resistant Staphylococcus aureus (MRSA) endocarditis and bacteremia, chronic thoracic osteomyelitis, chronic bilateral hip prosthetic joint infection, heart failure with reduced ejection fraction, severe mitral regurgitation, complete heart block with a permanent pacemaker, paroxysmal atrial fibrillation, and multiple additional comorbidities. He was transferred for hemoptysis and fever, and thoracoabdominal CTA was obtained to evaluate for an aorto-bronchial fistula. The CTA showed no evidence of aorto-bronchial fistula and demonstrated decreased peri-graft fluid compared with prior imaging. Systematic cardiac review demonstrated a focal anterior mitral leaflet defect with an adjacent 0.9 cm hypoattenuating lesion along the left atrial surface, suspicious for leaflet perforation with vegetation. The abnormality had not been reported on two transesophageal echocardiographs (TEEs) and four transthoracic echocardiographs (TTEs) performed earlier in the same year. This case highlights the complementary value of careful cardiac valve assessment on non-coronary CTA in patients with recurrent endocarditis and complex prosthetic cardiovascular material.