Cardiovascular flashlight 3751

doi:10.1093/eurheartj/ehy416
CARDIOVASCULAR FLASHLIGHT Online publish-ahead-of-print 17 July 2018
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Paravalvular root abscess with mycotic pseudoaneurysm
William K. F. Kong1,2,*, Chih Ching Choong3, Jai Ajitchandra Sule4, Kian Keong Poh1,2, and Theodoros Kofidis4
1
Department of Cardiology, National University Heart Centre, National University Health System, Singapore, 1E Kent Ridge Road, Singapore 119228; 2Yong Loo Lin
School of Medicine, National University of Singapore, Singapore; 3Department of Diagnostic Imaging, National University Health System, Singapore, 1E Kent Ridge Road,
Singapore 119228; and 4Department of Cardiothoracic and Vascular Surgery, National University Heart Centre, National University Health System, Singapore, 1E Kent
Ridge Road, Singapore 119228
* Corresponding author. Tel: 165 67725596, Fax: 165 6779 5678, Email: william_kong@nuhs.edu.sg

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An 80-year-old man with prior bioprosthetic aortic valve replacement for aortic regurgitation was admitted for worsening dysp-
noea, fever, and lethargy. Physical examination revealed an irregularly irregular heart rhythm and a soft early diastolic murmur in
the left lower sternal edge on auscultation. Electrocardiogram demonstrated atrial fibrillation with low voltage QRS, without evi-
dence of bundle branch block or conduction delay. Two sets of blood cultures showed growth of Staphylococcus aureus that were
sensitive to penicillin and vancomycin. A bedside transthoracic echocardiogram revealed widening of the intervalvular fibrosa
with a large pulsatile fluid pocket posterior to the bioprosthetic aortic valve, raising concern for an aortic root abscess with
mycotic pseudoaneurysm (Panel A, white arrow, Supplementary material online, Videos S1 and S2). A transoesophageal echocar-
diogram (TOE) confirmed an extensive aortic root abscess involving the entire root and had ruptured into the left ventricle

(Panel B, blue arrow). The abscess was located around the bioprosthetic aortic valve (Panel C, TOE 3D reconstruction, red
arrow) which had an infective vegetation and mild paravalvular leak without dehiscence. The multidetector computed tomogra-
phy also demonstrated the mycotic pseudoaneurysm located adjacent to the left main coronary artery (Panels D and E, black
arrows).
3752 Cardiovascular flashlight

The patient underwent aortic root repair with primary closure of the aorta-left ventricular fistula, primary closure of the pseudoaneur-
ysm wall, pericardial patch exclusion of the pseudoaneurysm cavity, and redo bioprosthetic aortic valve replacement on cardiopulmonary
bypass via a resternotomy. Endocarditic material can be seen on the excised aortic root and bioprosthetic valve (Panel F, dotted arrow).
Supplementary material is available at European Heart Journal online.

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