Medical history and current illness
62-year-old male with no known drug allergies. Hypertensive, dyslipidaemic and type 2 diabetic on treatment with oral antidiabetics. History of aortic valve replacement with implantation of Sant Jude number 27 mechanical prosthesis in 1998 due to severe aortic insufficiency of rheumatic aetiology, presenting as a complication post-surgical mediastinitis and tricuspid endocarditis due to penicillin-sensitive S. aureus, treated with penicillin and rifampicin and surgical debridement, with good evolution. Followed up annually in Cardiology outpatient clinic with good evolution, with last review with echocardiogram showing normal LVEF. Normal contractility. Normal functioning aortic prosthesis. Mild intraprosthetic aortic insufficiency. Mild mitral insufficiency. Baseline life: functional class I-II/IV. No oedema, no baseline orthopnoea. Usual treatment: synthroid, acovil 10, pravastatin and glicazide. She came to the hospital due to an increase in her usual dyspnoea over the last six months until she became moderately exertional, together with episodes of oppressive, non-radiating central thoracic pain lasting 15-20 minutes, independent of physical activity, with no other associated symptoms of heart failure, or at any other level.

Complementary tests
- Blood tests: haemoglobin 15 mg/dl, haematocrit %, leucocytes 8000/mcl (neutrophils 75%, lymphocytes 7%), platelets 205600 /mcl. Biochemistry: glucose 168 mg/dl, HbA1c 7.1, urea 39 mg/dl, creatinine 1.1 mg/dl, sodium 143, potassium 5.1, LDH 582, C-reactive protein 20.
- Coagulation: normal.
- Blood cultures: three positive samples for Enterococcus faecalis, sensitive to ampicillin and gentamicin. Urine culture: negative.
- ECG: RS at 90 bpm. Axis 60o. First degree BAV (280 ms) QRS less than 0.12. Poor progression of R in precordial leads. Rest normal.
- Transthoracic echocardiogram: LV slightly dilated, with end-diastolic diameter of 62 mm. No mild ventricular hypertrophy, normal LVEF (55%), with paradoxical septal motion, without other alterations of segmental contractility. LA slightly dilated (43 mm). Aortic metallic prosthesis with normal gradients (maximum gradient of 17 mmHg and mean of 9 mmHg). Aortic root slightly-moderately dilated (45 mm). Evidence of two yet at the level of ascending thoracic aorta with origin in its tubular sinus portion with orifices of 5 and 3 mm respectively, communicating with AD and velocities of 4-5 m/s. CCDD slightly dilated. No tricuspid insufficiency to estimate PSAP.
- Transesophageal echocardiogram: in the sinus portion of the aorta, immediately above the valvular plane, multiple pseudoaneurysmal saculations are seen protruding into both atria, with thinned walls. There is a shunt from the left coronary sinus to the right atrium. No shunt is seen between the aorta and RV.
- Chest X-ray on admission: CTI slightly increased.
- Chest CT with contrast: morphological and functional data: normal cardiac cavities. LV of 48 mm. Parietal septal thickness iv 8 mm, posterior wall 11 mm. Normal segmental contractility. Preserved LVEF (50%). VTD of 236 cc and VTS 120 cc. Dilated right ventricle. Atria not dilated. Aortic prosthesis with perivalvular pseudoaneurysmal images, the largest around the left coronary sinus. Below the coronary sinus and at subvalvular level there is a yet of 5 mm towards the right atrium. The mitral valve is morphologically normal. The rest is normal.

Clinical evolution
It was decided to admit the patient to hospital. During his stay, the patient remained haemodynamically stable. Broad-spectrum antibiotic treatment was started, being replaced by ampicillin and gentamicin after antibiogram. Extracorporeal surgery was performed with deep hypothermia and intermittent blood cardioplegia for adequate myocardial protection, with cannulation of both cavas and ascending aorta. Femoral arteries and veins are cannulated and median resternotomy and release of cardiac adhesions are performed.
Clamping of the ascending aorta was performed, with opening of the ascending aorta and right atriotomy, with visualisation of two perivalvular abscesses, one in the mitroaortic junction without fistula to the LA of 2-3 cm in diameter and another abscess at the level of the non-coronary sinus with fistulisation to the RA. The aortic prosthesis was explanted and the left cavity drained through the fossa ovalis and both abscesses were closed with a bovine pericardial patch sutured in a circular fashion and a Sant Jude Regent aortic prosthesis number 25 was implanted, with 15 U-shaped stitches and aortic root lavage. The aortomy and atriotomy were closed with double sutures and the perforation to AD from the right side with stitches supported by pericardium. All this, with adequate haemostatic controls afterwards.
With ischaemia time of 125 minutes and surgical time of 143 minutes. At the end of the surgery, a transesophageal echocardiogram was performed, with no evidence of flow inside the abscesses. During follow-up, the patient has improved functional class and ventricular volumes with LVEDD of 55 mm, with a slightly depressed LVEF of approximately 45%. Septal akinesia. Moderately dilated LA. Bidisc prosthesis with normal motion, with gradients in the range of normofunction. Aortic insufficiency with two intraprosthetic mild-grade jets.

Diagnosis
Subacute endocarditis on prosthetic valve due to Enterococcus faecalis complicated by multiple wall abscesses with fistulization to ad. Replacement of mechanical aortic prosthesis + closure of abscesses. Mild systolic dysfunction. Carrier of bicameral pacemaker in vvir pacing mode by displacement of atrial electrode. HBP. DL. Type 2 DM.
