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A 74 year old man presented with unstable angina and moderate aortic stenosis. He had an aortic valve replacement (Carpentier Edwards 19 mm porcine valve) and three reversed saphenous vein grafts to the first obtuse marginal, left anterior descending, and right coronary arteries. He was referred back three months later with a two week history of tiredness, night sweats, and weight loss of 5 kg. There was no history of any dental work or other surgical procedures after his cardiac operation. His temperature was 38.2°C and there were no peripheral stigmata of infective endocarditis.
Cardiac examination revealed a pansystolic murmur in the mitral area with a soft ejection murmur in the aortic area. Laboratory investigations showed microscopic haematuria, haemoglobin 97 g/l, white cell count 14 × 109/l, and an erythrocyte sedimentation rate of 83 mm in the first hour.
ECG showed second degree heart block (Wenckebach) with left bundle branch block pattern that was not present on previous ECGs. One of three sets of blood cultures grew Streptococcus bovis. The images on transoesophageal echocardiography were particularly striking. There was a perivalvar abscess of the mitral valve annulus extending from the anteromedial to the posteromedial part of the mitral valve (left) and colour flow Doppler showed perforation of the mitral valve annulus (right).