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A 50 year old man was admitted for deterioration in his general condition, with a temperature of 38.7°C, shivering and asthenia. His history included idiopathic cirrhosis of the liver with portal hypertension and type 2 diabetes. Eighteen months previously, his aortic valve had been replaced with a Carpentier-Edwards bioprosthesis to correct pronounced calcific nodular aortic stenosis.
On admission the following signs were noted: crepitants in the base of the lungs; transprosthetic aortic systolic murmur; hyperleukocytosis 18.3×109/l (normal < 11); thrombocytopenia 75×109/l (normal > 160); C reactive protein 145 mg/l (normal < 10); and negative blood cultures. Transoesophageal echocardiography revealed moderate aortic insufficiency secondary to partial displacement of the bioprosthesis, a circulating abscess with systolic expansion around the aorto-mitral trigonum (below left), and a vegetation attached to the aortic bioprosthesis (below right).
On commencement of antibiotic treatment (amoxicillin plus netilmicin), the patient’s general condition improved and the signs of inflammation waned. Five days later, the patient presented with acute pulmonary oedema and suffered cardiac arrest. Transthoracic ultrasound revealed massive aortic insufficiency and emergency surgery was performed. The aortic prosthesis was found to have almost completely come out so a Carbomedics model had to be implanted. The patient’s condition subsequently deteriorated with progressive multi-organ failure, and he died 16 days after the operation.