Bacteria can adhere to cardiac endothelium damaged by regurgitation or shunt jet; however, healthy cardiac endothelium is supposedly resistant to bacterial adhesion. Bacterial vegetations are most common on cardiac valves, but are rarely observed at other sites. We report a case of a vegetation on the surface of left ventricular muscle/subvalvular tissue without regurgitation or shunt jet. Transthoracic echocardiography did not detect the vegetation because of its unique location; however, transesophageal echocardiography (TEE) did detect. In conclusion, vegetations can form without exposure to regurgitation or shunt jet, and TEE is highly sensitive for detecting the vegetation in unusual locations.

We can safely treat mitral valve disease with mitral annular calcification using Sapien 3 valve through the incision of the right side of the left atrium under direct visualization preventing atrio-ventricular disruption and left ventricular outflow tract obstruction.