Pulmonary stenosis blood flow to pulmonary trunk blood in the R ventricle Ventral Septal Defect Increased pressure in the

he R Ventricle Over riding aorta Turbulent blood flow Endothelial injury

Streptococcus viridans normal flora in the mouth cavity

Injury to the mucousa of the mouth

Entry to the blood circulation Goes to the heart

Fibrosis and fibrocalcification

Platelet Plug Formation Streptococcus viridans binds to platelet membrane annular pulmonic stenosis Induction of platelet aggregation by Platelet aggregation-associated protein from the bacterial membrane Upregulation of fibrinogen binding platelet GP complex IIb-IIIa Fibrin and platelet thrombus formation Vegetation Mitral valve (aortic side)

Pulmonary infundibullar stenosis

confluent branch stenosis

Higher pressure on the Ventricular side

Aortic valve vegetation on the aortic side of the R coronary cusp Difficulty in closure of the valves Aortic insufficiency/regurgitation

Chordae tendeneae fuse Leaflet become thicker and more rigid Mitral opening shrinks Mitral stenosis Hypertrophied papillary muscle

Embolization of vegetation Undetected as vegetation by echocardiogram