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Porcine bioprosthetic aortic valve endocarditis with ring abscess and aortic stenosis
R E Girgis1, H Rosman, R del Busto
1Department of Internal Medicine, Henry Ford Hospital, Detroit, MI 48202.
Abstract:
Porcine bioprosthetic valve endocarditis is an infrequent but serious complication of valve replacement surgery. Ring (or annular) abscess is a frequent finding in mechanical valve endocarditis. In contrast, porcine valve endocarditis most often involves the cusps, and annular infection is uncommon. Porcine valvular dysfunction secondary to endocarditis usually takes the form of incompetence, whereas stenosis is less frequent. We report a case of a 76-year-old female who developed endocarditis with Staphylococcus epidermidis nine months after placement of a Carpenter-Edwards porcine aortic valve. Her initial presentation included complete heart block and moderate aortic stenosis. Transesophageal echocardiography aided the diagnosis by demonstrating large vegetations, while transthoracic echocardiography showed only slight thickening of the valve leaflets. At operation, there was a circumferential abscess around the sewing ring causing valve dehiscence and virtual discontinuity of the aorta from left ventricle. Valve degeneration and organisms within the cusps were observed on microscopy. This case illustrates two infrequent complications of porcine aortic valve endocarditis, namely massive annular abscess with invasion of the conducting system and aortic stenosis. It also demonstrates the utility and limitations of transesophageal echocardiography in the diagnosis of this disorder.
Insights
Porcine aortic valve endocarditis can cause rare but severe complications like annular abscess and aortic stenosis. This case highlights these infrequent issues and diagnostic imaging roles.
Area of Science:
- Cardiology
- Infectious Diseases
- Surgical Pathology
Background:
- Porcine bioprosthetic valve endocarditis is a rare complication of valve replacement surgery.
- Annular abscess is common in mechanical valve endocarditis but infrequent in porcine valves.
- Porcine valve dysfunction typically presents as incompetence, with stenosis being less common.
Observation:
- A 76-year-old female developed Staphylococcus epidermidis endocarditis nine months post-Carpenter-Edwards porcine aortic valve replacement.
- Initial symptoms included complete heart block and moderate aortic stenosis.
- Transesophageal echocardiography revealed large vegetations, while transthoracic echocardiography showed minimal leaflet thickening.
Findings:
- Surgical findings included a circumferential abscess around the sewing ring, leading to valve dehiscence and aortic-left ventricular discontinuity.
- Microscopy showed valve degeneration and organisms within the cusps.
- This case presented two rare complications: massive annular abscess affecting the conducting system and aortic stenosis.
Implications:
- This case underscores infrequent complications of porcine aortic valve endocarditis, including extensive annular abscess and aortic stenosis.
- It demonstrates the diagnostic utility and limitations of transesophageal echocardiography in such cases.
- Highlights the importance of considering rare complications and advanced imaging in prosthetic valve endocarditis management.