Mitral leaflet aneurysm and perforation in fulminant infective endocarditis: Insights from real-time three-dimensional echocardiography

Abstract

Infective endocarditis is a life-threatening condition with high morbidity and mortality, particularly in low- and middle-income countries. Amongst causes, enterococcal IE accounts for a substantial proportion of cases, with E. faecalis as the predominant species (90%). We report a 59-year-old man with arterial hypertension and type 2 diabetes mellitus who presented with asthenia, low-grade fever, and osteoarticular pain. Laboratory evaluation revealed severe anemia, leukocytosis, and thrombocytopenia. A new holosystolic mitral murmur prompted echocardiography, which identified vegetation, aneurysm, and perforation of the anterior mitral leaflet with severe regurgitation. Blood cultures confirmed E. faecalis, and appropriate antibiotic therapy was initiated. Despite rapid intervention and intensive care, the patient developed acute heart failure and died within 23 days of admission. This case illustrates the fulminant potential of E. faecalis IE complicated by complex mitral valve destruction, and underscores the importance of early recognition, real-time 3D echocardiography, and prompt multidisciplinary intervention in high-risk presentations.