HISTORY, CURRENT ILLNESS AND PHYSICAL EXAMINATION
Male, 59 years old.

History
Cardiovascular risk factors: ex-smoker, arterial hypertension (AHT), hypercholesterolemia, insulinised type 2 diabetes mellitus.
Severe apnoea-hypopnoea syndrome treated with continuous positive airway pressure (CPAP).
Peripheral arterial disease.
Implantation of mechanical aortic prosthesis for severe aortic stenosis 18 days ago.
Echocardiogram at discharge: biventricular function preserved and normofunctioning aortic prosthesis.
Treatment: ivabradine 5 mg /12 hours, furosemide 40 mg/24 hours, bisoprolol 10 mg/24 hours, atorvastatin 40 mg/24 hours, metformin 850 mg/12 hours, Lantus 38 IU at dinner, novorapid 10 IU at breakfast, acetylsalicylic acid 100 mg/24 hours, acenocoumarol.

Present illness
The patient came to the emergency department on Friday afternoon with malaise, fever with shivering and dyspnoea on minimal exertion for 24 hours. Cough with expectoration 5 days ago, currently in remission, without other focality. He denies chest pain. Given the history of aortic valve surgery 18 days ago, he was assessed by cardiology during his stay in the emergency department. Echocardioscopy showed mild concentric left ventricular hypertrophy (LVH) with preserved global and segmental systolic function, normofunctioning aortic prosthesis, known mild-moderate central mitral regurgitation, dilated LA, normal right chambers, absence of pericardial effusion. The patient was admitted to the infectious diseases unit for empirical treatment with ceftriaxone.

Physical examination
Blood pressure (BP) 135/70 mmHg on arrival at triage, at physician assessment 85/60 mmHG, rising to 100/60 mmHG after serum therapy (500 ml saline). Heart rate (HR) 80 bpm. Temperature 39.5oC. SatO2 91% on room air. Sweaty, well perfused, eupneic.
Mild jugular engorgement. Cardiac auscultation: rhythmic, aortic systolic murmur II/VI, prosthetic sounds. Pulmonary auscultation: minimal crackles in the bases. Normal abdomen. No oedema in the lower extremities.

COMPLEMENTARY TESTS
Electrocardiogram (ECG) in the emergency room: sinus rhythm at 75 bpm, atrioventricular block of 1o with PR 220 ms. Signs of LV hypertrophy.
Emergency laboratory tests: glucose: 242 mg/dl. Creatinine 0.53 mg/dl. Urea 19 mg/dl. GPT 29 U/l.
Bilirubin 0.8 mg/dl. Sodium 137 mEq/l. Potassium 4.4 mEq/litre. Calcium 8.6 mg/dl. Albumin 3.1 g/dl. CK 399 U/l. LDH 250 U/l. CRP 46.5 mg/l. PCT 0,36 ng/ml. Haemoglobin 9.7 g/dl. Haematocrit 31.0%.
Platelets 211 *10^3/μl. Leucocytes: 7.9 *10^3/μl. Neutrophils 72.7%. Neutrophils 5.7 *10^3/μl.
Lymphocytes 17.3%. Lymphocytes 1.4 *10^3/μl. Prothrombin time 49%. INR1.7. APTT 53 sg.
Fibrinogen 503 mg/dl.
Chest X-ray in the ED: no evidence of HF.
ECG on the ward: sinus rhythm with 2:1 atrioventricular block, QRS axis at 60o.
ST elevation in inferior face (II,III, and aVF) and ST descent in I-aVL.
Regulated transthoracic echocardiogram: non-dilated left ventricle with mild LVH with ejection fraction (LVEF) 50%. Hypokinesia of the inferior, posterior and basal face of the posterior septum, of the apical segment of the anterior septum, apical of the anterior face and strict apex. Thickened and sclerosed mitral valve with severe mitral regurgitation, unclear mechanism: no clear tenting or posterior leaflet stiffness. Mechanical aortic prosthesis with excrescent and mobile images in the left ventricular outflow tract (LVOT) compatible with endocardial grafts. No aortic regurgitation. Maximum transprosthetic gradient of 35 mmHg. Right ventricle slightly dilated, hypokinetic, with mild global dysfunction. Severe tricuspid insufficiency (TI). Vd-Ad gradient of 45 mmHg. No pericardial effusion. Diagnosis: images compatible with aortic endocarditis. Inferior and apical akinesia. Severe mitral and tricuspid regurgitation.
Catheterisation: left dominance. Severe two-vessel coronary artery disease: mid-distal anterior descending (AD) occlusion, subocclusive lesion in distal circumflex (Cx), posterior descending occlusion. Balloon aspiration and angioplasty was performed in the LAD and distal Cx with good results, except for the posterior descending artery, which remained occluded.
Transesophageal echocardiogram: hypermobile endocardial graft protruding into LVOT on aortic prosthesis with periaortic thickening suggestive of abscess.
In addition, a mobile image in the right atrium in continuity with the mitral abscess and very close to the tricuspid septal leaflet with severe TR. The mitral valve was explored and no endocardial warts were seen on the mitral valve, but there was moderate to severe mitral insufficiency in relation to tenting and central coaptation deficit. The overall LVEF is at the low limit of normal with hypocytosis of the inferior, posterior and posterior septum.

CLINICAL EVOLUTION
After admission to the Infectious Diseases department, fever of 38.5oC and shivering persisted throughout the weekend.
The blood cultures taken in the emergency department had been lost, so new blood cultures (HC) were taken on Saturday and antibiotic therapy was upgraded to vancomycin-levofloxacin as empirical treatment for fever without a clear focus. On Sunday, fever persisted, with a slight worsening of the general condition. On Monday there was an evident clinical worsening with hypotension despite fluid therapy, bradycardia and increased dyspnoea. The laboratory was notified of S. epidermidis growth in 4 of 4 bottles.
With these data, the cardiology department was contacted again for a new echocardiogram and clinical assessment. An ECG was performed showing 2nd degree 2:1 atrioventricular block (AVB) together with ST elevation in inferior leads with ST descent on the lateral side. On further questioning, the patient reported some intermittent precordial discomfort associated with dyspnoea since that morning. The transthoracic echocardiogram showed endocarditis over the aortic prosthesis and alterations in segmental contractility. In view of the clinical, electrocardiographic and echocardiographic findings, emergent catheterisation was performed.
After revascularisation, clinical worsening persisted with dyspnoea and haemodynamic instability (hypotension) and the patient was transferred to the intensive care unit for a transesophageal echocardiogram (TEE) and stabilisation. In view of progressive dyspnoea and the impossibility of tolerating TEE, orotracheal intubation and connection to invasive mechanical ventilation were performed, as well as the start of perfusion of noradrenaline and dobutamine at low doses, despite which instability persisted with significant bradycardia, for which reason a transient transjugular pacemaker was implanted.
With all the data and with the diagnosis of infective endocarditis on prosthetic aortic valve complicated with mitroaortic abscess, extension to tricuspid valve, AVB, septic coronary embolisms and cardiogenic/septic shock, emergency cardiac surgery was decided where aortic valve replacement with biological prosthesis, tricuspid valve replacement with biological prosthesis and mitral ring placement were performed. After 66 days in the ICU and multiple complications including acute renal failure requiring continuous venovenous haemodiafiltration, acute respiratory failure, pneumonia associated with mechanical ventilation due to gram-negative bacillus, acute tracheobronchitis due to A. fumigatus, persistent complete AVB, C. parapsilopsis bacteraemia associated with central venous catheter, ischaemic hepatitis, paralytic ileus, multifactorial encephalopathy with a significant component of hypoxia and significant truncal-diencephalic damage with persistent coma, and finally death.

DIAGNOSIS
Early endocarditis on mechanical prosthetic aortic valve due to Staphylococcus epidermidis.
Mitroaortic junction abscess with extension to tricuspid valve. Severe mitral and tricuspid regurgitation.
Atrioventricular block 2:1.
Acute myocardial infarction with lower ST elevation. Septic coronary embolisms in the dominant circumflex and anterior descending coronary artery. Thromboaspiration and balloon angioplasty over LAD and Cx.
Mixed cardiogenic/septic shock.
Emergent surgery for aortic, tricuspid and mitral ring valve replacement.
Death.
