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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 31, No 4, July/August 2020
218
AFRICA
Case Report
Tricuspid valve vegetation related to leaflet injury:
a unique problem of catheter malposition
Yan Chen, Hongxia Wang, Yun Mou, Shenjiang Hu
Abstract
The use of peripherally inserted central catheters (PICCs) has
expanded substantially for drug delivery in clinical practice in
recent years. However, PICC lines expose patients to poten-
tial complications associated with an increasing incidence of
infective endocarditis. We herein report a case of a 57-year-
old woman who was diagnosed with tricuspid valve endo-
carditis by echocardiography. The most probable cause was
direct injury to the tricuspid valve by the tip of a PICC line
with excessive length in the right heart. The vegetation disap-
peared with conservative treatment after removal of the PICC
line. Clinicians must maintain vigilance against any suspected
PICC-related infection in febrile patients with a PICC line.
For echocardiographers, precise evaluation of the position of
the PICC tip and the detection of endocarditis is important
to devise the optimal clinical strategy.
Keywords:
infective endocarditis, PICC-related complications,
echocardiography, right heart failure
Submitted 23/7/19, accepted 10/2/20
Published online 1/6/20
Cardiovasc J Afr
2020;
31
: 217–220
www.cvja.co.zaDOI: 10.5830/CVJA-2020-005
Right-sided infective endocarditis is an infrequent but life-
threatening complication of peripherally inserted central
catheters (PICC), with high morbidity and mortality rates.
1
Deep positioning of the PICC line and forceful injection through
it may lead to injury of the endocardium and predispose the
patient to bacterial deposition.
2
We herein report a case in which
we describe the necessity of echocardiography for confirming the
tip position of the PICC line and detailed assessment of the right
heart to assist in planning the clinical procedure.
Case report
A 57-year-old woman was admitted to our hospital because of
a two-month history of recurrent fever. She had been diagnosed
with myelodysplastic syndrome (MDS) 15 months earlier and
uneventfully completed four courses of chemotherapy with
decitabine in our hospital. Two months prior to admission, the
patient was hospitalised in another institute while waiting to
undergo bone marrow transplantation. She developed a fever
and was found to have a pulmonary fungal and bloodstream
infection with an epidermal staphylococcus (methicillin-resistant
coagulase-negative staphylococcus).
After undergoing combination antiseptic treatment, she was
clinically well with normal chest computed tomography (CT)
findings and a negative blood culture. Shortly thereafter, her
symptoms recurred with the same manifestation on chest CT and
blood culture. Although the clinician adjusted the patient’s drug
treatment, her symptoms were not completely relieved, and her
temperature ranged from 36.5 to 38.5°C with a body weight loss
of 5 kg within two months.
On admission, the patient exhibited progressive fatigue and
weakness. A complete blood count revealed a white blood cell
count of 6.7 × 10
9
cells/l, haemoglobin level of 63 g/l and platelet
count of 17 × 10
9
cells/l. She presented to our department for
cardiac evaluation.
Transthoracic echocardiography (TTE) showed a PICC line in
the right heart with a small echodensity (0.9 × 0.5 cm) on the tip.
In diastole, the PICC tip floated into the right ventricle (Fig. 1A).
In systole, it returned to the right atrium, but as it did so, the tip
stabbed the tricuspid valve. Additionally, a large homogeneous
echodensity (1.7 × 1.1 cm) was attached to the ventricular surface
of the anterior tricuspid leaflet (Fig. 1B). No other structural
or functional abnormalities were observed except moderate
tricuspid regurgitation with peak velocity of 3.5 m/s.
A postero-anterior chest X-ray, which was performed at the
time of the PICC placement before chemotherapy, showed that
the tip position was located near the superior vena cava/right
atrial junction (Fig. 2). Therefore, tricuspid valve endocarditis
with PICC migration was diagnosed.
The patient underwent drug treatment with vancomycin and
rifampin after removal of the PICC line, which had been in place
for about 15 months. Her temperature gradually normalised
after four weeks of conservative treatment but she developed
progressive respiratory distress and lower extremity oedema.
Repeat TTE showed that the tricuspid valve vegetation had
decreased in size (0.9 × 0.6 cm) and that her cardiac condition
had deteriorated (depressed left ventricular ejection fraction of
39% and small amount of effusion in the pericardial cavity).
Echocardiography and Vascular Ultrasound Centre, The
First Affiliated Hospital, College of Medicine, Zhejiang
University, Hangzhou, China
Yan Chen, MD
Hongxia Wang, MD
Yun Mou, PhD,
1193047@zju.edu.cnInstitute of Cardiology, The First Affilliated Hospital,
College of Medicine, Zhejiang University, Hangzhou, China
Shenjiang Hu, PhD