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Aortic root endocarditis

EACVI Valvular Imaging Box

Author : Dr. Andrea Perne.

Club 35 ambassador



  • Echocardiography is an invaluable technique as well in the detailed evaluation of different cardiac pathologies as well as in the acute setting. The emergency echocardiography is necessary for quick rule in and rule out of the most important and life-threatening pathologies and may be hypothesis generating which may be worked up with a thorough exam at a later point in time.
  • This case demonstrates the utility of an emergency echocardiography as a primary diagnostic tool followed by a detailed examination
  • A 77-years old patient was admitted to hospital with a history of coughing, fever and reduced overall condition.
  • Upon clinical exam, laboratory panel and chest x-ray he was diagnosed of having pneumonia and admitted to hospital on i.v.-antibiotics.
  • On the third night, the patient developed a respiratory insufficiency and couldn‘t be stabilized with diuretics and oxygen.
  • So he was transferred to the ICU where he had to be put on mechanical ventilation and hemofiltration due to multiorgan failure. After stabilization, a bedside echocardiography was performed.

Clinical case information



Emergency transthoracic echocardiography showing an abnormal structure at the septal leaflet of the tricuspid anulus.


Different echocardiographic window confirming the suspicious structure at the tricuspid septal leaflet with proximity to the aortic root



A transesophageal echocardiogram was performed which showed prominent thickening of the aortic root suggestive of endocarditis which had protruded to the right atrium.



The aortic root and the suspicious structure in 3D transesophaegeal echocardiography.


Imaging with the 3D-transesophageal probe with x-plane imaging failing to demonstrate direct contact between the endocarditic structure and the tricuspid valve.

Aortic root endocarditis - Course

The patient was taken to the operating room where he got an aortic valve and root replacement as well as a reconstruction of the tricuspid and the mitral valve.

The postoperative course was fine until, after 6 days the patient became hemodynamically unstable and had to be put on mechanical ventilation and catecholamines again.

A new transesophageal echocardiography was performed showing a big paraaortal cavity.


Transesophageal echocardiogram 9 days after the initial operation showing a large cavity in the aortic root. The differential diagnosis was a big abscess or a paraaortic hematoma.


  • Shortly after the echocardiogram, the patient‘s condition worsened and he finally died. The family denied an autopsy.
  • This case shall emphasize the role of echocardiography as a primary emergency tool to generate differential diagnosis and initiate the diagnostic steps as part of the further workup.
    Furthermore, the role of 3D imaging is underlined by enabling close evaluation of structures and their vicinity, which in lots of situation is of crucial importance.