Journal of Acute Care
Volume 2 | Issue 3 | Year 2023

A Salvage Procedure in a High-risk Case of Prosthetic Valve Endocarditis with Aortic Root Abscess and Valve Dehiscence: A Case Report

Pooja Natarajan1, Mahesh Prabhu2

1,2Department of Cardiothoracic Anaesthesia and Intensive Care, Freeman Hospital, Newcastle upon Tyne, United Kingdom

Corresponding Author: Pooja Natarajan, Department of Cardiothoracic Anaesthesia and Intensive Care, Freeman Hospital, Newcastle upon Tyne, United Kingdom, Phone: +4407442218036, e-mail:

Received: 06 November 2023; Accepted: 29 November 2023; Published on: 19 February 2024


Introduction: Aortic root abscess in prosthetic valve endocarditis (PVE) can be a life-threatening situation, especially when associated with dehiscence of the aortic annulus, which is reported in 0.1–1.3% of patients who undergo aortic valve replacement (AVR). Early diagnosis and timely intervention could aid in a positive outcome, even in a deteriorating patient. The ”endocarditis team” approach is very beneficial, especially in early diagnosis and surgical therapy.

Case description: A 70-year-old gentleman who was awaiting homograft aortic root replacement (ARR) was presented with a sudden onset of respiratory distress requiring emergency intubation, ventilation, and high doses of inotropes/vasoconstrictors. He had previously undergone tissue AVR, 5 months earlier, along with coronary artery bypass grafting. On examination, he was in a low cardiac output state, which correlated with his echo findings of severe biventricular dysfunction, aortic root abscess, loss of aorto-mitral continuity, severe periprosthetic valve regurgitation, and tricuspid valve vegetation. Hence, he was diagnosed with infective endocarditis (IE) complicated with PVE. After a detailed discussion with relatives about the high risk of mortality and morbidity, he underwent an emergency salvage homograft ARR surgery and was discharged from the hospital on day 12.

Conclusion: Although we come across many patients with PVE, management of emergency situations with dehiscence of the aortic annulus with root abscess can be a serious situation to tackle, and good teamwork with timely decisions taken will facilitate a good outcome.

Clinical significance: Echocardiography helps in the early diagnosis of IE and surgical decision-making for a salvage procedure in case of PVE with intracardiac abscess and dehiscence of aortic annulus.

How to cite this article: Natarajan P, Prabhu M. A Salvage Procedure in a High-risk Case of Prosthetic Valve Endocarditis with Aortic Root Abscess and Valve Dehiscence: A Case Report. J Acute Care 2023;2(3):158–160.

Source of support: Nil

Conflict of interest: None

Keywords: Aortic root abscess, Case report, Life-threatening, Prosthetic valve endocarditis


Infective endocarditis (IE) has a 15–30% in-hospital mortality, with the incidence ranging from 3 to 10 cases/100,000 people per year. The multidisciplinary ”endocarditis team,” including cardiologists, cardiac surgeons, anesthesiologists/intensivists, and specialists in infectious diseases, is invaluable in the treatment of these high-risk patients.1 The cornerstone for diagnosis is echocardiography and blood culture. The main indications of surgery in prosthetic valve endocarditis (PVE) are heart failure, prevention of embolization, and severe infection, especially in left-sided disease.1


A 70-year-old gentleman (body surface area: 1.73 m2) was admitted to the ward for a redo aortic valve surgery for PVE. He had undergone aortic valve replacement (AVR) with coronary artery bypass grafting 5 months ago for aortic regurgitation but remained unwell and was investigated for IE. He was an ex-smoker with a medical history of type 2 diabetes mellitus and renal calculi. The blood cultures were negative, so he was managed conservatively. While waiting for surgery, he developed a sudden onset of breathlessness and hemodynamic deterioration. Hypoxia and severe hypotension were treated with fluid boluses, airway intubation, ventilation, and high doses of vasoconstrictors/inotropes after transferring him to the intensive care unit for an emergency salvage procedure. Bedside transesophageal echocardiography (TEE) revealed severe biventricular failure and extension of aortic root abscess into the base of the anterior mitral leaflet and the aorta. There was a severe paravalvular leak and vegetation on the tricuspid leaflet. After a detailed discussion with relatives about a high risk of mortality and morbidity, he was taken for an emergency salvage procedure at high risk as his Euro score II was 69% (Euro score: 18, logistic: 75.78%).

Intraoperative TEE supported the preoperative findings (Figs 1 and 2). A homograft aortic valve root replacement with tricuspid valve vegetation excision was performed. The left coronary and the right coronary buttons were secured to the homograft. On coming off cardiopulmonary bypass (CPB) after 369 minutes and an aortic cross-clamp time of 179 minutes, the patient had severe biventricular dysfunction requiring high inotropes/vasoconstrictors to maintain a mean arterial pressure (MAP) of 60 mm Hg. An intra-aortic balloon pump (IABP) was inserted to ease coming off CPB after resting the heart on CPB. The patient was administered relevant antibiotics as advised by the microbiologist. Cultures were sent from the root abscess and vegetation. He was shifted to the intensive care unit with moderate support, IABP, and continuous cardiac output monitoring with a pulmonary artery catheter. A target of MAP 65 mm Hg, cardiac index of 2–2.5 L/minute/m2, mean pulmonary artery pressure of <15 mm Hg, central venous pressure of <10 mm Hg, urine output of 0.5–1 mL/kg/hour, pulmonary mixed venous saturation of >60% and lactate <2 mmol/L. The patient was extubated on postoperative day (POD) 1, inotropes/vasoconstrictors weaned off by POD 3, IABP removed and shifted to the ward on POD 4. The patient was discharged from the hospital on day 10 postsurgery.

Fig. 1: Mid-esophageal aortic valve short-axis view showing aortic root abscess with paravalvular leak

Fig. 2: Tricuspid valve showing vegetation in mid-esophageal right ventricular inflow view


The European Society of Cardiologists have clearly recommended [evidence: class of recommendation (COR) IIA, level B] in the 2015 guidelines that any complicated IE, especially PVE, needs an ”endocarditis team” approach with referral to a tertiary care center and multidisciplinary team approach,1 transesophageal echocardiogram is recommended (COR II, level B) for the diagnosis of IE.1 The guidelines also mention that surgery should be the first choice (COR I, level of evidence B) for the treatment of an uncontrolled infection to prevent neurological or embolic complications or acute cardiac failure. However, surgical mortality remains high, up to 41% in a few studies.2,3 A meta-analysis done by Chen et al. showed that the 30-day mortality remained as high as 20% in patients with aortic root abscess.4 Mayer et al. conducted a study with 100 cohorts and found increased mortality in patients who received aortic root replacement (ARR) when compared to AVR.5 Anguera et al. showed that Staphylococcal aureus is the most common pathogen known to cause PVI.6 Koo et al. mentioned that the incidence of prosthetic aortic valve dehiscence after AVR is reported to be 0.1–1.3%.7 Early diagnosis and treatment with echocardiography could facilitate a positive postoperative outcome.


Aortic root abscess, especially with PVE, can be detrimental to life as it could lead to rupture of abscess causing pericardial tamponade, intracardiac shunts causing cardiac failure, cardiogenic/septic shock state and embolization causing strokes. Echocardiography helps in early diagnosis and intervention, which could make a difference in the patient’s outcome.

Clinical Significance

Echocardiographic diagnosis of PVE at the earliest, especially in a hemodynamically unstable patient with timely intervention, could help in a good outcome postsurgery despite having a calculated high risk of mortality.


Pooja Natarajan


1. Habib G, Lancellotti P, Antunes M J et al. 2015 ESC guidelines for the management of infective endocarditis: the Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J 2015;36(44):3075–3128. DOI: 10.1093/eurheartj/ehv319

2. Anguera I, Miro JM, Vilacosta I, et al. Aorto-cavitary fistula in endocarditis working group. Aorto-cavitary fistulous tract formation in infective endocarditis: clinical and echocardiographic features of 76 cases and risk factors for mortality. Eur Heart J 2005;26(3):288–297. DOI: 10.1093/eurheartj/ehi034

3. Bashore TM, Cabell C, Fowler V Jr. Update on infective endocarditis. Curr Probl Cardiol 2006;31(4):274–352. DOI: 10.1016/j.cpcardiol.2005.12.001

4. Chen GJ, Lo WC, Tseng HW, et al. Outcome of surgical intervention for aortic root abscess: a meta-analysis. Eur J Cardiothorac Surg 2018;53(4):807–814. DOI: 10.1093/ejcts/ezx421

5. Mayer K, Aicher D, Feldner S, et al. Repair versus replacement of the aortic valve in active infective endocarditis. Eur J Cardiothorac Surg 2012;42:122–127. DOI: 10.1093/ejcts/ezr276

6. Anguera I, Miro JM, Cabell CH, et al. Clinical characteristics and outcome of aortic endocarditis with periannular abscess in the International Collaboration on Endocarditis Merged Database. Am J Cardiol 2005;96:976–981. DOI: 10.1016/j.amjcard.2005.05.056

7. Koo HJ, Yang DH, Kang JW, et al. Demonstration of prosthetic aortic valve dehiscence in a patient with noninfectious aortitis by multimodality imaging: findings of echocardiography and computed tomography. Circulation 2013;128(7):759–761. DOI: 10.1161/CIRCULATIONAHA.112.000749

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