Case description
A 67-year-old man with aortic bioprosthesis, implanted in 2012 in the
setting of native aortic valve (AoV) IE, underwent a redo surgery -
Bentall procedure with new AoV bioprothesis - after early PVIE in 2013.
No known risk factors or drug abuse.
In 2017, he was admitted to hospital with fever with one-week
evolution-time. Physical examination was unremarkable except for fever
and tachycardia. Blood analysis showed elevated systemic inflammatory
markers. He was hospitalized for further study. Transthoracic (TTE) and
transesophageal echocardiography (TEE) revealed the presence of thin
filiform vegetations in the right coronary cusp, with no local
complications. No signs of systemic embolization. The diagnosis of PVIE
was made and empiric antibiotic therapy was started, later directed to
methicillin-sensitive Staphylococcus aureus (SA) identified in blood
cultures. The patient remained febrile and developed complete
atrio-ventricular (AV) block. A transvenous temporary pacemaker was
implanted and TEE was repeated which disclosed a perivalvular abscess
involving the anterior the AoV ring (Figure 1A, B, C). Serial
echocardiographic assessments showed abscess expansion involving the
entire prosthetic ring, pseudoaneurysm formation and mild paravalvular
regurgitation (Figure 1D, E, F). Cardiac computed tomography depicted
the massive pseudoaneurysm of the aortic root (AoR) with bilateral
communication with the left ventricle (LV) (Figure 2).
The case was addressed in Heart Team: due to massive destruction of
cardiac structures, he was ineligible for AoV replacement and was
proposed for HT. He recovered from AV block, with no signs of heart
failure or systemic embolization. Repeated sets of blood cultures were
sterile after 6 weeks of antibiotic therapy. He was discharged home
while on waiting list for HT. Serial echocardiograms were performed,
which depicted preserved LV function, mild aortic regurgitation and the
AoR pseudoaneurysm with similar features over time. After eight months
of outpatient follow-up, he was successfully transplanted and had an
uneventful postoperative course. Despite the dreadful presentation, he
remains asymptomatic 3 years after HT.