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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 10  |  Issue : 2  |  Page : 62-64

Two aortic root pseudoaneurysms in infective endocarditis in a patient with bicuspid aortic valve


Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran

Date of Submission14-Mar-2021
Date of Acceptance08-May-2021
Date of Web Publication29-Jul-2021

Correspondence Address:
Dr. Mohammad Esmaeil Zanganehfar
Vali-Asr Ave. 1995614331, Tehran
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/rcm.rcm_13_21

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  Abstract 


Infective endocarditis can cause several major complications, including valvular destruction, aneurysm formation, and aortic ring abscesses, and pseudoaneurysm formation in left ventricular outflow tract (LVOT) is quite a rare complication of infective endocarditis. Here, we present a rare case which had two simultaneous LVOT pseudoaneurysms, a bicuspid aortic valve (BAV) and abscess formation along with the presence of anerobic bacteria (Peptostreptococcus) in the tissue culture. We describe echocardiographic, computed tomography angiography findings, and the result of surgical repair. This is a unique case with 2 LVOT pseudoaneurysms, a BAV, and anerobic bacteria in the tissue culture which became complicated as a result of delayed intervention due to fear of coronavirus disease 2019.

Keywords: Bicuspid aortic valve, infective endocarditis, Peptostreptococcus


How to cite this article:
Parhizgar SE, Zanganehfar ME, Kiani R, Pouraliakbar HR, Kaviani R, Kamali M, Vahedinezhad M, Sanavi AF. Two aortic root pseudoaneurysms in infective endocarditis in a patient with bicuspid aortic valve. Res Cardiovasc Med 2021;10:62-4

How to cite this URL:
Parhizgar SE, Zanganehfar ME, Kiani R, Pouraliakbar HR, Kaviani R, Kamali M, Vahedinezhad M, Sanavi AF. Two aortic root pseudoaneurysms in infective endocarditis in a patient with bicuspid aortic valve. Res Cardiovasc Med [serial online] 2021 [cited 2021 Dec 4];10:62-4. Available from: https://www.rcvmonline.com/text.asp?2021/10/2/62/322580




  Introduction Top


Overdiagnosis of coronavirus disease 2019 (COVID-19) and misleading in management of patients presenting with septic symptoms (e.g., fever and chills in patient with infective endocarditis) in addition to panic hesitation to comprehensive work-up for such symptoms may lead to patient neglect in many septic syndromes.

Formation of pseudoaneurysms as a result of infective endocarditis has been reported frequently. Abscess formation is also an infectious complication which may result from delayed or inappropriate management of such cases. Regarding their symptoms such as fever and chills, suitable treatment and proper approach to patients with infective endocarditis during pandemics are of high level of importance regarding their possible destructive aftermath.


  Case Report Top


Herein, we describe a 52-year-old woman, a known case of severe aortic stenosis and regurgitation secondary to a bicuspid aortic valve (BAV). The patient was scheduled for elective surgery, which was postponed due to the exigencies of the coronavirus disease 2019 (COVID-19) pandemic. She was suffering from fatigue, occasional low-grade fevers, and dyspnea on exertion commencing 1 month before her presentation. During this period, she was visited by internists several times with the impression of probable COVID-19. Due to her persistent fever and history of valvular disease, she was referred to our tertiary center for further evaluation.

Upon arrival at the emergency department, the patient had a blood pressure of 109/83 mmHg, a heart rate of 90 bpm, and a low-grade fever (37.6°C axillary). In relevant workup for infective endocarditis, transthoracic echocardiography revealed a very thick and calcified BAV with severe aortic stenosis (peak pressure gradient = 91 mmHg, mean pressure gradient = 61 mmHg, and aortic valve area by continuous equation = 0.77 cm2) with moderate-to-severe aortic regurgitation (holodiastolic flow reversal in the descending aorta) and a dilated ascending aorta (4.8 cm). Multiple mobile shaggy masses suggestive of vegetation on the ventricular side of the leaflets (largest size = 6 mm × 5 mm) and importantly 2 pulsatile echo-free spaces (18 mm × 22 mm and 10 mm × 14. 8 mm) were found in the anteroproximal and posteroproximal portions of the aortic root, respectively, with a to-and-fro flow, suggestive of a pair of pseudoaneurysms [Figure 1].
Figure 1: Transthoracic echocardiography shows a pseudoaneurysm in the posteroproximal portion of the aortic root in the parasternal long-axis view (orange arrow), a pseudoaneurysm in the anteroproximal portion of the aortic root in the parasternal long-axis (yellow arrow) and parasternal short-axis (white arrow) views, and a destroyed aortic valve (blue arrow)

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An infectious disease specialist was consulted, and relevant septic workups – including blood culture and abdominopelvic ultrasonography – were performed. Parenteral antibiotic therapy, comprised of intravenous vancomycin (1 g twice daily) and intravenous meropenem (1 g every 8 h), was commenced.

In further evaluation, a multislice spiral computed tomography angiography of the thoracic and abdominal aorta and the coronary arteries revealed a thickened and calcified BAV, which had been destroyed and had a perforated commissure, and a large pseudoaneurysm arising from the left ventricular outflow tract (LVOT) and protruding toward the main pulmonary artery and the left anterior descending artery. Also depicted was another smaller pseudoaneurysm protruding posteriorly toward the left atrium [Figure 2].
Figure 2: Computed tomography angiography of the aorta shows a large pseudoaneurysm (white arrow), a small pseudoaneurysm (black arrow), and a destroyed, perforated, and thickened aortic valve with vegetation (yellow arrow)

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The first blood culture test revealed Peptostreptococcus, an anerobic Gram-positive nonspore organism. The antibiotic therapy was, therefore, adjusted to antibiogram as continuing vancomycin and discontinuation of meropenem. Then, a cardiac surgeon was consulted. Accordingly, on the 5th day of her hospitalization, the patient was transferred to the operating room. Despite the planned reconstructive and aortic valve replacement surgery (the Bentall procedure), maximum debridement of the site tissue was required due to obvious abscess formation below the left coronary cusp. As a result of this, there remained tiny and insufficient amount of tissue for aortic root replacement. Hence, aortic valve replacement was performed without aortic root replacement. Postoperative transthoracic echocardiography revealed a mechanical bileaflet prosthetic aortic valve with good leaflet motion and hemodynamics (the mean pressure gradient = 4 mm Hg and the acceleration time = 67 ms), as well as mild paravalvular leakage from the swing ring. Intravenous antibiotic was continued for 4 weeks after the operation. In her 3-month follow-up visit, the patient was doing well with acceptable echocardiography study.


  Conclusion Top


Anerobic bacteria are the suspected microorganisms in between 2% and 16% of cases with infective endocarditis. Infective endocarditis caused by Peptostreptococcus species arising mainly from dental, genitourinary, and joint infections is a rare but fatal condition because of related complications such as valvular destruction, aneurysm formation, and aortic ring abscesses.[1] The major risk factor for such a condition is a preexisting cardiac valve pathology.[2] which in our case was a BAV. Pseudoaneurysm formation in LVOT is quite a rare complication of infective endocarditis, and unfortunately, our patient had a pair of them. LVOT pseudoaneurysms usually arise from the mitral-aortic intervalvular fibrosa, and the protrusion can result in mitral regurgitation, myocardial ischemia in the left anterior descending artery territory, aorto-ventricular tunnels, and even cardiac tamponade, if they rupture toward the pericardial space.[3] Several case reports have demonstrated pseudoaneurysm formation in the aortic root[4],[5],[6] and the mitral-aortic intervalvular fibrosa,[7],[8] as well as fistula formation,[9],[10] as a result of infective endocarditis.

While it is shown that during COVID-19 pandemic, emergency department referrals have declined as people are hesitant to leave home and risk contracting the infection by attending hospital, people, including patients and health-care workers need clear guidance and information and should be fully aware that the risks of delayed presentation to hospital care for medical conditions can be much higher than those posed by COVID-19.[11],[12]

Nonetheless, based on our literature search, our case is unique in that she had 2 LVOT pseudoaneurysms, a BAV, and abscess formation along with the presence of anerobic bacteria in the tissue culture which may probably become complicated due to delayed intervention as a result of COVID fear in both physicians and the patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Brook I. Infective endocarditis caused by anaerobic bacteria. Arch Cardiovasc Dis 2008;101:665-76.  Back to cited text no. 1
    
2.
Verdecia J, Vahdat K, Isache C. Trivalvular infective endocarditis secondary to Granulicatella adiacens and Peptostreptococcus spp. IDCases 2019;17:e00545.  Back to cited text no. 2
    
3.
Da Col U, Ramoni E, Di Bella I, Ragni T. An unusual left ventricular outflow pseudoaneurysm: Usefulness of echocardiography and multidetector computed tomography for surgical repair. Cardiovasc Intervent Radiol 2009;32:188-91.  Back to cited text no. 3
    
4.
Uchida T, Uchino H, Kuroda Y, Nakashima K, Shimanuki T, Kanauchi N, et al. Left ventricular outflow tract pseudoaneurysm complicated with prosthetic valve endocarditis after aortic valve replacement. Kyobu Geka 2012;65:196-200.  Back to cited text no. 4
    
5.
Yadav K, Sharma M, Agarwal S, Bhatia N, Yadav N. Aortic pseudoaneurysm and endocarditis caused by Aerococcus viridans: A case report and literature review. Cardiovasc Revasc Med 2018;19:201-3.  Back to cited text no. 5
    
6.
Guaricci AI, Musci RL, Santis D, Argentiero D, Sgarra L, Losito C, et al. An atypical pseudoaneurysm as complication of prosthetic aortic-valve endocarditis. Future Cardiol 2017;13:533-7.  Back to cited text no. 6
    
7.
Watanabe S, Matsuoka T, Minagawa T, Miura M, Shimizu T, Kawamoto S, et al. Aortic root pseudoaneurysm due to avulsion of aortic valve commissure following to infective endocarditis; report of a case. Kyobu Geka 2018;71:1027-30.  Back to cited text no. 7
    
8.
Zencirkıran Ağuş H, Atamaner O, Uygur B, Kalkan AK, Ertürk M. Infective endocarditis of a bicuspid aortic valve complicated by septal aneurysm and mitral-aortic intervalvular fibrosa pseudoaneurysm. Turk Kardiyol Dern Ars 2018;46:147-50.  Back to cited text no. 8
    
9.
Moaref A, Shahrzad S, Aslani A. Acquired aortoventricular tunnel: A rare complication of infective endocarditis. Echocardiography 2009;26:82-3.  Back to cited text no. 9
    
10.
Gurbuz AS, Alsancak Y, Ozcelik A, Ozer SF, Duzenli MA. A rare echocardiographic image of aortic prosthetic valve endocarditis complicated with paravalvular abscess, pseudoaneurysm and aorto-right atrial fistula. Echocardiography 2018;35:1484-6.  Back to cited text no. 10
    
11.
Lee-Archer P, Blackall S, Campbell H, Boyd D, Patel B, McBride C. Increased incidence of complicated appendicitis during the COVID-19 pandemic. J Paediatr Child Health 2020;56:1313-4.  Back to cited text no. 11
    
12.
Lazzerini M, Barbi E, Apicella A, Marchetti F, Cardinale F, Trobia G. Delayed access or provision of care in Italy resulting from fear of COVID-19. Lancet Child Adolesc Health 2020;4:e10-1.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2]



 

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