3D Transgastric Views in Transesophageal Echocardiography (TEE) to Diagnose Isolated Pulmonary Valve Endocarditis: When the Standard Views Fall Short

Isolated pulmonary valve endocarditis (PVE) is a rare and diagnostically challenging form of right-sided infective endocarditis, often lacking the typical findings seen with left-sided or tricuspid valve involvement. We describe an 83-year-old man with end-stage renal disease on hemodialysis, who developed persistent Staphylococcus aureus bacteremia despite appropriate antibiotics and catheter exchange. Standard diagnostic methods, including physical examination, laboratory tests, and transthoracic echocardiography, were unremarkable. Initial transesophageal echocardiography (TEE) with conventional views was limited by acoustic shadowing. Ultimately, transgastric two-dimensional (2D) and three-dimensional (3D) TEE imaging revealed vegetation on the pulmonary valve, leading to the diagnosis. The patient improved with ongoing therapy, and further imaging was deferred by agreement. This case highlights the need to consider isolated PVE in patients with persistent bacteremia and intravascular devices, even without classic risk factors. It also emphasizes the value of advanced imaging, particularly transgastric 3D TEE, for detailed assessment of the pulmonary valve when conventional studies are inconclusive. A multidisciplinary approach involving infectious diseases, nephrology, and cardiology is essential for prompt diagnosis and effective management. In summary, comprehensive imaging and a high index of suspicion are critical for identifying isolated PVE, which should remain a differential diagnosis in select high-risk patients with unexplained bacteremia.