TCTAP C-214
Structural - Imaging - Echocardiography
A Challenging Case Report of Abiotrophia Defectiva Infective Endocarditis Complicated by a Ruptured Pseudoaneurysm of the ATS Aortic Valve Replacement Extending to the Right Ventricle, Along With Ruptured Chordae of the Mitral and Tricuspid Valves
Teerana Uisrikoon1, Surapan Pongsuthana1, Wittawat Wattanasiriporn1, Jaidwarong Thanakitcharu1
Rajavithi Hospital, Thailand1,
Clinical Information
Patient initials or Identifier Number
Relevant Clinical History and Physical Exam
She presented with dyspnea and prolong fever 2 weeksU/D : HT,DLP, post aortic valve replacement (ATS no.23) and post CABG x II (LIMA – LAD, SVG – OM) in 2018V/S : BP 98/66 mmHg, BT 36.6 C, PR 68 bpm, RR 22 /min. She was inserted ET tube due to dyspneaHEENT : Giant CV waveHeart : Median sternotomy scar, soft S1 and closing clickat S2, continuous murmur at RUPSB, PSM at apex radiate to axilla gr. III, PSM grade III at LLPSBLung : Fine crepitation both lower lungsExt: Pitting edema 2+
Relevant Test Results Prior to Catheterization
TTE
Finding :
-Good LVEF
-Aortic annular ectasia with outpouching annulus through LV
-Echo drop-out between aorta / LV to RV with continuous flowacross it
-Moderate prosthetic aortic valve regurgitation (2 jets-central and peripheral jets) suspected paravalvular leakage
-Severe MR, posterior direction jet
IMP :
-Suspected pseudoaneurysm of prosthetic AV with rupturesinus of Valsava
-Suspected paravalvular leakage of prosthetic AV
-Severe MR
Hemoculture : Abiotrophia defectiva
Relevant Catheterization Findings
TEE
Finding :
-Seen thick wall out-pouching of aorta with continuous flowfrom aorta to pseudoaneurysmand throughout RV
-Seen paravalvular leakage of prosthetic aortic valve
-Seen vegetation at anterior mitral valve leaflet withsevere MR
-Seen thickening chordae tendinea of tricuspid valve
IMP :
-Suspected ruptured pseudoaneurysm of aortic valve to RV (Flow Ao-pseudoaneurysm-RV)
-Suspected IE of MV and TV with severe MR and severe TR
Interventional Management
Procedural Step
Intraoperative finding :
-Ascendingaortic root diameter 5.5 cm
-Prostheticvalve IE of aortic valvewith paravalvularleakage of R-L commissures
-Aorto-LV-RVfistula was seen
-Vegetationof anterior mitral valve leaflet with rupturedchordae tendinea withsevere MR
-Vegetationof anterior tricuspid valve leaflet with rupturedchordae tendinea withsevere TR
-Leftside SVC
Procedure
-AVR replacement with On-X No. 19
-MVR replacementwith SJM No. 25
-TVR replacementwith Hancock No. 25
-Ascendingaortic replacement with graft DIM 30 mm
-Aorto-LV-RVfistula was closed by closure patch
Case Summary
1. We report an extremely rare case of Abiotrophia defectivainfective endocarditis complicated by a ruptured pseudoaneurysm of the aorticvalve extending to the right ventricle, along with ruptured chordae of themitral and tricuspid valves. Due to its very low incidence, it presents both adiagnostic and therapeutic challenge.2. Abiotrophia defectiva is a rare cause of infectiveendocarditis and is often difficult to isolate in blood cultures. Commonlyfound in the gastrointestinal tract. Uniquely, this patient’s blood cultureswere positive, enabling early identification of the infection and promptinitiation of targeted antibiotic therapy.
