When endocarditis evolves to abscess and surgery becomes solution

Introduction: Perivalvular abcess is a rare complica-tion of infective endocarditis, usually associated with prosthetic valve and most frequently having an aortic location. The main ethiologic agent is Staphylococcus aureus, and for the best diagnosis is indicated transe-sophageal echocardiography with a detection sensiti-vity of 86%. The importance of early detection of this complication is given by the negative prognostic, with a high mortality rate despite surgical treatment (41%). Methods: We present the case of a 71 years old patient, hypertensive, diagnosed in June 2018 with severe aor-tic stenosis, moderate aortic regurgitation and infecti-ve endocarditis of the aortic valve with Streptococcus viridans, for which he followed an antibiotic protocol with negative blood cultures and absence of endocardi-tis vegetation after 1 month. Currently, about 6 months later the patient is hospitalized with acute pulmonary edema, clinically presenting with an altered general condition, dyspneic, with bilateral leg edema, a IV/ VI systolic murmur with a maximum intensity in the aortic area, afebrile on admission but with one febrile episode during hospitalization.

Results: The electrocardiogram showed sinus tachycar-dia 100 b/min, transient LBBB frequency dependent, then sinus rhythm 75 b/min with left ventricular hypertrophy. The blood tests indicated the absence of inflammatory syndrome on admission, however with the dynamic increase of C-reactive protein, negative blood cultures. Transthoracic echocardiography reve-aled severe aortic stenosis, severe aortic regurgitation, no evidence of addition images, moderate-severe mi-tral regurgitation, moderate tricuspid regurgitation. Transesophageal echocardiography showed an aortic perivalvular ecofree space near the right non-coronary cusp suggestive of aortic perivalvular abscess, a calci-fied aortic valve without addition images. The disco-very of the aortic perivalvular abscess, possibly a late complication of the previous valvular endocarditis required the re-initiation of antibiotic treatment and guidance to cardiovascular surgery. The surgical inter-vention allowed, besides solving the acute infectious complication, the correction of the double valvular le-sion by prosthesis, with significant improvement of the cardiac hemodynamics and implicitly of the patient’s life quality and long-term prognosis.

Conclusions: On a patient without clear signs of an in-fectious endocarditis recurrence in the absence of fever, initial inflammatory syndrome and positive hemocul-tures, but having an increased risk in the presence of double aortic lesions and history of endocarditis, tran-sesophageal echocardiography is the essential investi-gation that establishes the diagnosis and then guides the therapeutic course. The particularity of the case consists in the late di-agnostic of the perivalvular abscess and its evolution despite the antibiotic treatment followed. The occur-rence of the abscess on a native valve and the invol-vement of a microorganism rarely associated with this complication (S. viridans) are also particular.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
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CODE: 379
CME Credits: 10 (Romanian College of Physicians)
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