A 65 year old man with severe aortic stenosis presented with high fever and chills, two weeks after cardiac catheterisation. Staphylococcus epidermidis was isolated in blood cultures. Transoesophageal echocardiography (TOE) revealed a large mobile vegetation, 13 mm in size, attached on the aortic wall above the origin of the left main coronary artery (panels A and B). The patient was managed with antibiotics according to the sensitivity of the microorganism but failed to improve.

On the fifth day of the treatment the patient suffered an acute cerebral embolic event with right sided hemiplegia, aphasia which was complicated with clinical signs of heart failure. A new TOE showed disappearance of the vegetation. An aortic abscess had been formed extending and infiltrating the aortic cusps (panel C) causing severe aortic regurgitation. Blood cultures continued to be positive.

Surgery was performed confirming the findings. During the operation a bileaflet mechanical prosthesis was inserted, because of technical difficulties for using an aortic composite graft. Four days after the operation a third TOE study showed signs of persisting inflammation at the affected region (panel D) with good function of the prosthesis. The patient died a few days later in sepsis and multiorgan failure.

This case shows the evolution of ascending aorta bacterial infection as assessed by TOE. Although the incidence of aortitis and/or endocarditis after cardiac catheterisation is extremely rare, this cannot be excluded in our patient.

Transoesoephageal echocardiography. At 120°, the presence of a vegetation (arrowhead) above the origin of the left main coronary artery can be appreciated. AV, aortic valve; AO, ascending aorta; LA, left atrium; LV, left ventricle.

The full extent of the vegetation is visualised at 64°. RA, right atrium.

The vegetation has disappeared. An aortic abscess (arrowhead) has been formed extending and infiltrating the aortic cusps.

The proximal ascending aortic wall is thickened (arrowhead) with a small echolucent space indicating persistence of the inflammation. PrV, aortic prosthetic valve.