Abstract 12115: TAVR Endocarditis Complicated by Aortic Root Pseudoaneurysm

Abstract

Case Presentation: An 83-year-old man with hypertension, hyperlipidemia, atrial fibrillation, non-obstructive CAD, and severe AS status post TAVR 4 months prior was transferred from an outside hospital with reported persistent fever for one week. He had no other procedure recently including dental work. He was found to have staphylococcus epidermidis bacteremia in multiple blood cultures. His outside hospital TEE showed pulsatility of the non-coronary sinus with possible vegetations on the noncoronary cusp of the TAVR. On physical examination, he was afebrile, normotensive, and well appearing. His cardiovascular examination, laboratory tests, and chest radiograph were unremarkable, and he denied any chest pain or shortness of breath. His ECG revealed rate-controlled atrial fibrillation. A cardiac CTA revealed a 6 mm mobile hypodense thickening of the non-coronary prosthetic cusp, suspicious for vegetation and a contrast opacifying outpouching in the aortic root near the aorto-mitral curtain, suspicious for pseudoaneurysm. The patient underwent TAVR explantation, pseudoaneurysm exclusion, and AVR using a 23 mm bioprosthesis (Figure). He was discharged 8 days later on antibiotic treatment. At follow-up, the patient felt well with no complaints. Discussion: TAVR endocarditis with resulting aortic root pseudoaneurysm is an immensely rare entity, where there is lack of clinical data with regards to management. Guidelines of prosthetic valve endocarditis (for both TAVR and SAVR) recommend surgical treatment in such cases, although this recommendation was mostly based on the SAVR literature and many patients who undergo TAVR are at higher surgical risk at baseline. Recent studies on TAVR explantation showcase the risky nature of surgery in these patients, with high mortality rates, making treatment decisions less clear. Careful multidisciplinary discussion of risk and benefits is vital to guide clinical decision making in these complex patients.