Bicuspid aortic valve is commonly associated with infective endocarditis with serious peri annular complications. We report a case of 37-year-old male patient presented with infective endocarditis involving bicuspid aortic valve with leaflet perforation and severe aortic regurgitation. Mitral valve was involved secondary to aortic valve endocarditis as a kissing lesion with severe mitral regurgitation. Anterior mitral leaflet (AML) had aneurysmal dilatation with mobile vegetations inside it. In colour Doppler, AML aneurysm was looking like a fireball inside the left atrium. Patient was treated with antibiotics and referred to surgery for aortic and mitral valve replacement.

Bicuspid aortic valve is the most common congenital heart lesion; it is found in 1%–2% of the general population. Infective endocarditis (IE) is a well-recognized complication (prevalence 0.4/100000) and usually presents in the fourth and fifth decades of life1.Rarely it can involve the mitral valve as a kissing lesion or drop lesion. We report a case of 37-year-old male presented with infective endocarditis of bicuspid aortic valve with anterior mitral leaflet (AML) aneurysm as a kissing lesion from aortic valve vegetation.

A 37-year-old male patient presented with low grade intermittent fever of 15 days duration. On examination, patient had pallor, raised jugular venous pressure (JVP) with prominent v wave, high volume collapsing pulse with peripheral signs of aortic run off. Blood pressure (BP) was 130/40/0. Cardiovascular system examination revealed hyperdynamic apex, loud P2, pansystolic murmur in mitral area & early diastolic murmur in neoaortic area. Clinically diagnosis of severe aortic regurgitation with severe mitral regurgitation with pulmonary arterial hypertension was made.

Electrocardiogram (ECG) showed sinus rhythm left ventricular (LV) enlargement with volume overload, left atrial enlargement. Chest x ray showed LV cardiomegaly with pulmonary venous hypertension. Blood investigations revealed anaemia (Hb8g/dl), leucocytosis with elevated acute phase reactants. Blood culture showed growth of streptococcus mitis sensitive to Ceftriaxone & gentamycin. Echocardiography revealed bicuspid aortic valve with anterior posterior orientation (FIGURE 1B,) with severe aortic regurgitation (FIGURE 2). Mobile grapelike vegetations were seen attached to the aortic valve leaflets (FIGURE 1A). A globular unruptured aneurysm of anterior mitral leaflet was seen with mobile vegetations inside the aneurysm (FIGURE 3). Severe mitral regurgitation was noted. Trans oesophageal echocardiography (TEE) with 3D reconstruction revealed oval shaped perforation of posterior aortic leaflet measuring 1.5 x 0.7 cm. It also demonstrated AML perforation(0.9 x 0.9) with unruptured aneurysm (FIGURE 5) measuring 1.3 x 1.3 cm along with aortic valve vegetations touching the AML aneurysm (FIGURE 4 ) suggestive of “KISSING LESION” of AML. In colour Doppler, the aneurysm is looking like a FIRE BALL in the heart (FIGURE 4). Patient was treated with antibiotics and advised for double valve replacement.

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Congenital bicuspid aortic valve is common and, in most cases, remain undetected until infection or calcification supervenes. It is one of the most common cardiac predispositions for native valve endocarditis (NVE)2.  IE is severe and tends to occur in the fourth and fifth decades of life, requiring major surgery in most cases. Mortality   associated with bicuspid aortic valve IE is 28%, according to the study by Skehan et al3. There is a high incidence of serious complications, specifically heart failure (72%) and aortic root abscesses (30%). As in NVE in general, staphylococci (12% of them are coagulase negative) and viridans streptococci accounted for nearly three-quarters of the cases affecting bicuspid aortic valves2. In our case we isolated streptococcus mitis as the causative organism.

Mitral valve involvement secondary to IE of bicuspid aortic valve is exceedingly rare. Three mechanisms are proposed for the spread of infection5. First, “drop” lesion, where the jet of Aortic regurgitation strikes the AML & embeds organisms causing abscess or aneurysm5. Second, “kissing” lesion, where aortic valve vegetations prolapse into LVOT touching the AML5. Third, “contiguous” spread of infected tissue from aortic valve to AML5. Drop lesion of AML caused by klebsiella pneumonia was reported from our institute4. This time we report this case of KISSING lesion of AML from infective endocarditis involving bicuspid aortic valve – a “fireball in the heart”.

Kissing lesion in mitral valve with aneurysm of anterior mitral leaflet secondary to aortic valve vegetations is a rare entity but can occur. Timely diagnosis is necessary to prevent complications and improve outcome.