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Cardiovascular Images
August 14, 2019

A Middle-aged Man With Aortic and Mitral Valve Endocarditis

Author Affiliations
  • 1Division of Cardiology, University Hospital, London Health Sciences Centre, Western University, London, Ontario, Canada
  • 2Department of Social and Preventive Medicine, Université Laval, Quebec City, Quebec, Canada
  • 3Department of Medicine, University of Toronto, Toronto, Ontario, Canada
JAMA Cardiol. Published online August 14, 2019. doi:10.1001/jamacardio.2019.2811

A middle-aged man presented to the clinic with subacute fevers and decompensated heart failure. Auscultation demonstrated a left-sternal, decrescendo, early diastolic murmur; a soft middiastolic rumble; and an apical, blowing, holosystolic murmur. Blood cultures grew Streptococcus mitis, and transesophageal echocardiography delineated bicuspid aortic valve and anterior mitral valve leaflet vegetations, confirming endocarditis (Figure, A). A color Doppler echocardiographic image revealed a torrential aortic regurgitation jet striking the anterior mitral leaflet, causing premature middiastolic rebound into the left ventricular inflow tract (Figure, B; Video). These findings were consistent with the Austin Flint phenomenon, in which early mitral closure by a turbulent regurgitant aortic jet generates a middiastolic murmur.1,2