Intramyocardial paravalvular abscess after aortic valve replacement

Abstract

A 59-year-old man was transferred to our radiology department because of general deterioration and a left ventricular ejection fraction of 50%. Besides diabetes mellitus type II, his medical history included a significant aortic valve stenosis and ischemic heart disease for which a combined intervention was performed with prosthetic aortic valve replacement (ON-X-23) and coronary artery bypass grafting 7 years previously.Three weeks earlier he had been admitted at a general hospital for atrial fibrillation with a fast ventricular response. After successful pharmacological reconversion to sinus rhythm he was discharged from hospital within a week. Because of prostatitis he had been taking ciprofloxacin for 7 days, 250 mg twice a day. Eight days later he was admitted again because of poor general condition, confusion and dyspnoea with intermittent fever, up to 38,5°C. Pleural fluid and a consolidation were seen on chest computed tomography. Combined antibiotic therapy was started. Blood cultures and culture of the pleural fluid were negative. Despite this therapy, blood sedimentation and C-reactive protein remained high. No vegetations were seen on transesophageal echocardiography but empirical amikacin was started because of suspected prosthetic valve endocarditis. Left ventricular ejection fraction was 50%.On admission in our university hospital he was alert and oriented, but ill. He had lost 10 kg of weight in the last 2 months. He was apyrexial, had a regular heart rhythm of 90 bpm and a blood pressure of there was limited lower extremity oedema. An electrocardiogram showed a left bundle branch block.A PET-CT was performed for two reasons: to find an infectious origin of the suspected endocarditis and, because of his weight loss, nicotine (36 pack years) and alcohol abuse (5-6 U/day), to exclude a neoplasm.