What are the next steps in diagnosis and treatment after noting a mobile mass on the aortic valve?

From the Guidelines

The next steps after identifying a mobile mass on the aortic valve should include immediate transesophageal echocardiography (TEE) for better visualization, followed by blood cultures to rule out infective endocarditis, as recommended by the American College of Cardiology 1. The initial evaluation of the aortic valve morphology can be performed with transthoracic echocardiography (TTE), but TEE is essential for a more detailed assessment, especially in cases with a high suspicion of endocarditis or a subaortic membrane.

Key Considerations

• Blood cultures should be obtained to rule out infective endocarditis, and empiric antibiotic therapy should be initiated promptly, typically with vancomycin 15-20 mg/kg IV every 12 hours plus ceftriaxone 2g IV daily, while awaiting culture results.
• Additional workup should include complete blood count, inflammatory markers (ESR, CRP), and cardiac biomarkers.
• Surgical consultation is essential as many aortic valve masses require surgical intervention, particularly if the mass is large (>10mm), mobile, or associated with embolization.
• Anticoagulation with heparin may be considered if the mass is suspected to be a thrombus rather than vegetation.
• The patient should be monitored closely for signs of systemic embolization, heart failure, or valvular dysfunction.
• The urgency of intervention depends on the suspected etiology, with infective endocarditis requiring more immediate action compared to fibroelastomas or other benign tumors, as outlined in the guidelines for the management of patients with valvular heart disease 1.

Diagnostic Approach

• Echocardiography is indicated to confirm the diagnosis of aortic valve disease, assess the cause and severity of the disease, and evaluate left ventricular dimension, mass, and systolic function.
• Cardiac magnetic resonance imaging (CMR) or ECG-gated multidetector computed tomography (MDCT) can be used to evaluate valve anatomy and function if additional imaging is needed.
• The diagnosis of chronic severe aortic regurgitation can usually be made on the basis of the diastolic murmur, displaced left ventricular impulse, wide pulse pressure, and characteristic peripheral findings, as described in the guidelines for the management of patients with valvular heart disease 1.

From the Research

Next Steps in Diagnosis

• After noting a mobile mass on the aortic valve, the next steps in diagnosis may include:
  • Transthoracic echocardiography (TTE) to assess the aortic valve morphology and the severity of aortic valve disease 2
  • Transesophageal echocardiography (TEE) to further evaluate the mobile mass and its attachment to the aortic valve 3, 4
  • Multislice CT or cardiac magnetic resonance (CMR) to visualize the aortic valve and surrounding structures 4, 2
  • Laboratory testing to rule out systemic infection and evaluate for antiphospholipid antibodies 3

Differential Diagnosis

• The differential diagnosis of a cardiac mass attached to the aortic valve includes:
  • Infection (endocarditis) 3
  • Tumor (e.g. papillary fibroelastoma) 4
  • Thrombus 3, 5
  • Antiphospholipid antibody syndrome 3

Treatment Options

• Treatment options for a mobile mass on the aortic valve depend on the underlying cause and may include:
  • Anticoagulation therapy for antiphospholipid antibody syndrome or thrombus 3, 5
  • Surgical excision of the mobile mass for papillary fibroelastoma or other tumors 4
  • Antibiotic therapy for endocarditis (if present) 3
  • Vigilant observation and monitoring for changes in the size or characteristics of the mobile mass 3