An Aortic Root Abscess Mimic Identified by Multi-disciplinary Imaging Review: a Case Report

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Abstract Background While echocardiography and cardiac Positron Emission Tomography (PET) can aid in the diagnosis of prosthetic valve endocarditis (PVE), post-operative changes can lead to false-positive imaging findings. We report a case of a patient with an aortic valve prosthesis with remnant BioGlue deposits mimicking a paravalvular abscess on imaging in the setting of suspected PVE. Case Summary A 67-year-old man presented with two days of fever, chills, and altered mentation. He had a history of two prior aortic root replacements—nineteen and four years prior to his presentation. He had blood cultures that were persistently positive for Pseudomonas aeruginosa. Initial transesophageal echocardiogram (TEE) was notable for a thickening of the posterior aortic root thought to be consistent with post-surgical changes. Cardiac PET showed significant uptake around the prosthetic aortic valve, concerning for a paravalvular abscess. However, given the patient’s high risk for re-do surgery, clearance of blood cultures and preserved valve function, our multidisciplinary endocarditis team (MET) recommended non-surgical management, and close follow-up. After six weeks of appropriate antibiotics, a TEE demonstrated concern for an evolving paravalvular abscess. The MET performed extensive review of his prior surgical interventions and cardiac imaging, revealing the previous use of surgical BioGlue and stability in the aortic root on imaging, consistent with non-infectious post-surgical changes and conservative management was recommended. Discussion Thorough review of prior interventions and serial imaging in patients with suspected PVE through a multidisciplinary team approach is essential in elucidating the complete, often complex, clinical picture and recommending the most appropriate management.