A 47-year-old male patient came to our centre to rule out acute coronary syndrome.

History, current illness and physical examination
A 47-year-old male patient from the Philippines, with no known toxic habits or drug allergies.
Pathological history: hypertension treated with ARA II. Moderate severe aortic insufficiency with last echocardiogram in 2004 with preserved EF. First degree AV block (PR 300-320 msec). No other history of interest.
Current illness: Consultation to the emergency department for cough and fever. He was discharged with a diagnosis of bronchial infection and was prescribed treatment with amoxicillin-clavulanic acid and nebulisations. Ten days later, he re-consulted at another hospital due to persistent cough, to which dyspnoea and mechanical lumbar pain were added. He denied fever, febrile equivalents or symptoms suggestive of bacteraemia. A thoraco-abdominal CT scan ruled out pulmonary thromboembolism and discordant aortic aneurysm, but a pulmonary infiltrate was observed in the left upper lobe. Laboratory tests showed CRP 41 mg/dl, the only determination of TnT US 103 ng/L. At that time he was referred to our centre to rule out acute coronary syndrome.
Physical examination in the emergency department: Good general condition, conscious and oriented. BP: 124/50, Axillary T.: 36.4, SatO2: 99% Cardiovascular: Regular sounds, 2/4 pandiastolic murmur. No IY, no RHY. No oedema or signs of deep vein thrombosis. Pulses symmetrical, alive and jumping. No carotid murmurs. Respiratory: Bladder murmur preserved, no other added sounds. Digestive: No signs of peritonism, positive right renal fist percussion. Neurological: No signs of neurological focality or meningism.

Complementary tests
- Laboratory tests: Urea 36 mg/dL, creatinine 0.86 mg/dL, sodium 140 mmol/L, potassium 4.04 mmol/L, chlorine 108 mmol/L. CRP 7.4 mg/dL. Hb 10.8 g/dL. Leukocytes 10,500 cells/mm3. Platelets 280.000, PT 64%. Urine sediment: S5 red blood cells, S0 leukocytes. Sputum BK (1st) negative. Urine Ag (pneumococcus and legionella) negative.
- ECG: Sinus rhythm. FC 68 bpm. PR 320 msec (already described). QRS duration 100 msec. QRS 0° QTc axis 420 msec. Criteria left ventricular enlargement. Non-specific intra-ventricular conduction disorder.
- Chest X-ray: Condensation in LSI.
- Thoracic-abdominal CT angiography (reviewed by the Radiology Department of our centre): Large cardiomegaly with a certain component of heart failure (reflux of contrast towards the hepatic veins) in addition to a focus of sub-pleural condensation in LSI with a ground-glass halo that could correspond to a pneumonic focus. Renal micro-density of less than 1 cm, non-specific. No other findings of note.

Clinical evolution
An echocardiogram was performed which showed an image suggestive of vegetation 10 mm in the bicuspid aortic valve. Severe aortic insufficiency. In the mitral valve, perforation of the anterior leaflet with moderate-severe insufficiency. Ascending aorta 45 mm. Global hypokinesia, left ventricular ejection fraction 45%, mild tricuspid insufficiency. Moderate pulmonary hypertension. At that time the Cardiology Service was notified. Physical examination revealed signs of heart failure. Electrocardiogram showed PR lengthening up to 400 msec.
Given the suspicion of endocarditis complicated by heart failure, valvular rupture and possible abscess in the aortic annulus, it was decided to transfer the patient to the Coronary Unit to await surgery. Treatment was started with ampicillin, gentamicin and cloxacillin. Blood cultures were negative at all times. Due to intraventricular conduction disturbance, a provisional MCP was implanted and a transesophageal echocardiogram was performed which showed an abscess at the mitro-aortic junction draining into the left ventricular outflow tract (LVOT) and fistulisation into the right atrium (RA). Non-invasive digital angiography with pre-surgical multi-detector CT showed no significant coronary lesions and confirmed the LVOT-to-AD fistula.
Surgical intervention revealed vegetations in the right coronary and non-coronary leaflets of the aortic valve, with extension to the anterior mitral leaflet of the mitral valve. The aortic valve was replaced with a 21 mm mechanical prosthesis and the mitral valve was replaced with a 27 mm mechanical prosthesis, preserving the mitro-aortic junction.
Antibiotic treatment was continued with amipicillin, gentamicin and cloxacillin. Blood cultures, catheter and surgical specimen cultures were negative. Due to persistent episodes of advanced atrioventricular block (AVB), on the fifteenth post-operative day, a permanent VDD pacemaker was implanted without incident. Due to the appearance of pleural and pericardial effusion, with auscultation of pericardial friction rub, treatment was started with ASA and colchicine. Due to persistent pericardial effusion and the appearance of haemodynamic compromise, pericardiocentesis via the left anterior subcostal route was decided. The puncture was performed without complications. A fluid with haematic characteristics was obtained and sent for analysis.
After removal of approximately 800 cc of fluid, a negative pressure drainage system was left in place. Post-procedural ECHO showed a significant reduction in pericardial effusion, with persistent posterior predominance of fluid, now with better expansion of the right cavities compared to the previous ECHO. Since then, haemodynamically stable with blood pressure of 130/70 mmHg and improvement of his general condition. At 24 hours the drain was removed with a total extraction of 950 cc. Echocardiogram after removal of the drain: moderate pericardial effusion predominantly inferoposterior. Despite this, 24:00 hours after removal of the pericardial drain, he complained of intense dizziness and profuse sweating accompanied by hypotension 93/50 mm Hg. In view of the suspicion of new tamponade, a portable echocardiogram was performed which showed anterior pericardial effusion, especially basal (25 mm) with echoes inside suggesting haematoma with compression of the RV, which could not be approached by subcostal puncture, for which reason the patient was again referred to Cardiac Surgery for urgent surgery. The patient evolved favourably after surgery and was discharged home after 2 weeks postoperatively.

Diagnosis
Aortic valve endocarditis with negative blood cultures complicated by:
- Severe aortic insufficiency
- Mitral insufficiency due to perforation of the anterior mitral leaflet
- Secondary heart failure
- Periaortic abscess
- Complete atrioventricular atrial ventricular block secondary to abscess
- Left ventricular outflow tract fistula to left atrium secondary to abscess.
