Transcatheter Aortic-Valve Endocarditis Confirmed by Transesophageal Echocardiography

Abstract

70-year-old white man was admitted to the Department of Vascular Surgery with a critical right forearm ischemia caused by acute thromboembolic occlusion and underwent operative embolectomy. Microbiological testing revealed colonization of the embolus with Staphylococcus lugdunensis and S. epidermidis. Because of pain in the lower thoracic spine, elevated C-reactive protein, and a recent history of spondylodiscitis with evidence of coagulase-negative Staphylococcus spp., the patient was transferred to the Department of Neurosurgery 16 days after vascular surgery. S. epidermidis was then isolated from blood cultures. The patient had a history of coronary heart disease with reduced left ventricular function, atrial fibrillation, diabetes mellitus, and hemodialysis resulting from diabetic nephropathy, as well as kidney transplantation and subsequent kidney transplant failure in 2000. The patient was taking no immunosuppressive medication at admission. He had had a transcatheter aortic valve (CoreValve, Medtronic) implanted 12 months before as a result of severe native valve stenosis (logistic EuroSCORE, 33.11% at the time of implantation). He was transferred to our echocardiography laboratory with persistently elevated levels of C-reactive protein. Three months before transthoracic and transesophageal echocardiography (Movies I and II in the online-only Data Supplement), he was negative for signs of prosthetic valve endocarditis (PVE). Two- and 3-dimensional transesophageal echocardiography now showed an elongated mass 3 cm in length floating around a longitudinal axis within the stent lumen of the prosthetic valve. Apparently, the mass was attached to the stent struts. In addition, there were signs of a paravalvular abscess at the noncoronary sinus (Figure 1 and Movies III through V in the online-only Data Supplement). Minor paravalvular regurgitation was present at the left coronary sinus. The native valves did not show any signs of endocarditic lesions. The peak velocity across the valve had increased by ≈140 cm/s (Figure 2). After echocardiographic diagnosis of PVE and initiation of calculated antibiotic therapy with vancomycin, gentamicin, and rifampicin, the patient was transferred to the Department of Cardiac Surgery. The infected valve was replaced by a porcine valve (Hancock II, Medtronic; diameter 25 mm) under extracorporeal circulation. Intraoperative findings confirmed massive lesions on the biological parts of the transcatheter valve consistent with PVE (Figure 3). Surprisingly, 3 to 4 stent struts had penetrated the aortic sinotubular junction close to the noncoronary sinus. The valve was