Case Report
Patient history prior to current observation :
A 77-year old man, with a history of diabetes, arterial hypertension and implantation of a permanent DDD pacemaker for symptomatic AV block , was referred to Cardiac Surgery due to severe aortic stenosis and replacement with Carpentier nº21 bioprosthesis. A coronariography that proved to be normal was previously performed. During the next months the patient experienced intermitent episodies with fever, loss of appetite and weakness.
Clinical findings on admission, evolution and outcome :
Two and half months later he presented to our emergency department with persistent fever and chills. The results of standard laboratory analyses, chest X-ray, 12-lead ECG and his physical examination were within normal limits. Enterobacter aerogenes was isolated in four sets of blood culture bottles. Transesophageal echocardiography (ETE) showed no signs of prosthetic endocarditis. The patient was treated initially with vancomicine and gentamicine but developed acute renal failure from nephrotoxicity. Then, he improved clinically with a course of intravenous cloxaciline and levofloxacin and was discharged from hospital. Four months later the patient´s family brought him back with intense dyspnea and fever. The valuation was completed carring out a new ETE that demonstrated a pseudoaneurysm at the posterior –coronary sinus region with holodiastolic high flow velocity inside (video 1,2,3,4) . The intimal flap was confined to only 1-cm segment of aortic annulus. Normal values of prosthetic valve Doppler parameters were measured and no valve regurgitation or fistulization was evident. Severe impairment left ventricular function was revealed. The patient refused surgery and preferred home treatment and heart failure care. He died six months later.