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.