To the Editor:
A 41-year-old woman presented with a 2-week history of neck and back pain and suddenly developed pulseless electrical activity cardiac arrest while in the emergency department, with return of spontaneous circulation after 2 rounds of advanced cardiac life support. Physical examination and labs were notable for fever, sinus tachycardia, leukocytosis, and lactic acidosis. She was started on broad-spectrum antibiotics due to concern for sepsis. A transthoracic echocardiogram followed by a transesophageal echocardiogram demonstrated an elongated, highly mobile, atypical vegetation attached to the anterior mitral leaflet, measuring 9.85 cm in length with mild mitral regurgitation (Figure). The vegetation moved into the left ventricle during diastole and into the left atrium during systole (Supplementary Video, available online). The blood cultures ultimately grew methicillin-resistant Staphylococcus aureus. Despite appropriate antibiotic therapy, she developed persistent altered mentation, and magnetic resonance imaging of the brain confirmed multiple septic emboli. She later developed neurologic compromise and died.
A thin, elongated intracardiac mass may represent infective vegetation, chordal rupture, false tendon, strands of sewing rings of prosthesis, or redundant chordae from congenital, rheumatic, degeneration, or a fibroelastic deficiency.1, 2, 3 Primary chordae attach to the leaflets and have an average length of approximately 20 mm.4When chordae become thin and extended, they may rupture, demonstrating a similar echocardiographic appearance.2
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-Leonard Riley, MD, Jorge Lascano, MD, Ali Ataya, MD
This article originally appeared in the May issue of The American Journal of Medicine.
