HISTORY, CURRENT ILLNESS AND PHYSICAL EXAMINATION
57-year-old woman with a history of hypertension, diabetes mellitus and chronic atrial fibrillation. She has had a mitral valve prosthesis for six months (surgery at a private centre in March 2014) due to a double rheumatic mitral lesion with severe mitral regurgitation (MR). The preoperative echocardiogram also showed a moderate double aortic lesion, moderate pulmonary hypertension and non-dilated left ventricle with preserved systolic function. On chronic treatment with aldocumar, digoxin, metformin/vildagliptin, carvedilol, spironolactone, escitalopram and furosemide.
She was referred from a private clinic for progressive dyspnoea in the last three weeks to the point of minimal effort, two-pillow orthopnoea and episodes of paroxysmal nocturnal dyspnoea. She has not presented chest pain or other associated symptoms. No infectious episodes since surgery, fever or febrile fever. No recent invasive dental or surgical procedures.

On examination she had: ʟʟ BP: 108/74 mmHg. hR: 94 bpm. ʟʟʟ Ta: 36 °C. ʟʟʟ Cardiac auscultation: arrhythmic, with presence of mitral click, systolic murmur in aortic focus IV/VI and systolic murmur in tricuspid focus. pulmonary auscultation: crepitant sounds in both bases. No other relevant findings.

COMPLEMENTARY TESTS
ECG: atrial fibrillation at 93 beats per minute, with evidence of systolic overload. Blood tests: haemogram within the normal range, biochemistry and renal and hepatic function parameters without alterations, INR 1.9. There was a discrete mobilisation of myocardial damage markers in plateau (troponin I 1.9-1.7 ng/mL); NT-ProBNP 20528, HbA1C 8.6% and ESR 25. Blood cultures were negative in two independent determinations. Chest X-ray on admission: mitral valve prosthesis and reinforcement of the peribronchovascular mesh, with no other significant findings. Initial transthoracic echocardiogram (TTE) and serial transesophageal echocardiograms (TEE).
Initial TTE: left ventricle slightly hypertrophic, dilated (VTD 154/ VTS 115 ml), with severe depression of LVEF (by Simpson 25%). Global hypokinesia. MAPSE 8 mm. Mitral filling pattern with single E wave. Dilated LA, AP diameter 68 mm, area 48 cm2. Sclerocalcified aortic valve, with limited opening (M-mode 0.8). Double aortic lesion, both of which appear moderate. Maximum gradient 33, mean 21.5 mmHg; IVT AVAo of 0.9 cm2 (LVOT diameter 18 mm), with low systolic volume (47 mL). Moderate aortic insufficiency. Mechanical mitral prosthesis with correct opening of both hemidiscs. Maximum velocity 2 cm/s. No significant leaks. Right ventricle with DTD in apical 4C of 40 mm at basal level, midventricular of 31 mm. TAPSE of 10 mm. S" wave 5 cm/s. Dilated RA. Moderate TR. RV-AD gradient of 45 mmHg. IP trivial. Transpulmonary acceleration time 85 ms. Dilated IVC (20 mm) that does not collapse with inspiration. No pericardial effusion.
ETE 1: FEVI <20%. Preserved mitral prosthetic opening, maximum velocity 1.7 m/s. Mild periprosthetic leak. Images on mitral annulus of morphology and density compatible with thrombotic tamponade and less probably pannus. Image on ventricular side of prosthetic annulus interposed between disc and annulus, causing mild insufficiency. Dense spontaneous contrast effect in LA and left atrial appendage. Image in the LA roof at the mouth of the left pulmonary veins showing thrombus. Calcified trivalve aortic valve, with severely reduced opening but could be due to reduced transvalvular volume (VAo planimetry 0.7 cm2). Aortic annulus 19 mm. Ascending aorta 31 mm. Dilated RV, tricuspid annulus 45 mm. Moderate TR. No intracardiac shunts.
TEE 2: partial resolution of the echodense image around the mitral prosthetic ring. It presents two mobile images: the largest (13x9 mm) anchored in the anterior annulus, retroaortic, low echogenicity, deflected, which prolapses in diastole through the annulus. The smallest in the posterior annulus (4 mm). Compatible in this context with evolution to residual hypermobile thrombus as first option. No periprosthetic insufficiencies. Image compatible with fixed mural thrombus at the entrance of the left atrial appendage. Significant smoke effect in the entire atrium. There is still a mural echodense image at the bottom of the left atrium in relation to the origin of the right pulmonary vein described in the previous study.
TEE 3: large echodense image in the atrial side of the mitral prosthesis that generates complete blockage of the anterior prosthetic disc, with transprosthetic gradients: maximum 8.1 and average 3.8 mmHg. Significant smoke effect in the left atrium and in the atrial appendage, the latter presenting an image suggestive of upholstery on its lateral wall. Coronary angiography: non-significant stenosis in the ostial trunk, around 30%. The rest of the coronary arteries had no lesions.

EVOLUTION
Patient with the aforementioned history, with a mitral prosthesis for six months, admitted for heart failure. Diuretic treatment was started with a good response and systolic function and valve functionality were re-evaluated. Transthoracic echocardiography (TTE) showed severe left ventricular systolic dysfunction with a normally functioning mitral prosthesis and moderate-severe aortic stenosis. In evaluation with transesophageal echocardiography (TEE), an image compatible with intraventricular thrombus lining the mitral annulus was observed and treatment with sodium heparin and ASA was started. Subsequent echographic controls showed an increase in its size, which came to block the anterior prosthetic disc despite APTT in the appropriate range. Blood cultures were taken and were negative in serial determinations. The patient was stable and afebrile, in good general condition and ambulating around the ward, with no evidence of heart failure.
On the tenth day of admission, she presented acute pain in the right lower limb, with a sensation of paraesthesia and distal pallor and echo-Doppler data of acute ischaemia of the right lower limb. Urgent transfemoral embolectomy of the right external iliac artery was performed, with recovery of distal pulses and triphasic Doppler flow on leaving the operating theatre. With the diagnosis of suspected prosthetic thrombosis with poor evolution complicated by peripheral embolism, urgent surgery was requested on prosthetic mitral valve and aortic valve replacement, as the patient met the criteria for this. Surgical cleaning of the mitral prosthesis was carried out, which was found to be covered and partially blocked by a mass that appeared to be a large thrombus, and sent to the microbiology laboratory for analysis. The aortic valve was also replaced with a metallic prosthesis. The patient was admitted to the resuscitation unit sedated, haemodynamically stable and respiratory stable with invasive mechanical ventilation.
Eight hours after admission to the unit, a positive result was reported for Aspergillus in the septifast of the "mitral valve thrombus", so treatment was started with amphotericin B and voriconazole and the case was re-evaluated, and a new urgent surgery was scheduled for removal of the mitral prosthesis. Intracardiac cleaning with amphotericin B and implantation of a new mechanical prosthesis was performed without complications during the procedure. Adequate stabilisation was achieved with suspension of vasoactive agents and extubation was performed after 48 hours, with good tolerance.

Five days after surgery, the patient had decreased visual acuity in the right eye. On neurological examination she presented right homonymous haemianopsia on threat examination, with no other alterations. An urgent cranial CT scan was performed, which revealed a 2.5 cm cystic lesion in the left occipital lobe with adjacent oedema compatible, in the clinical context of the patient, with aspergilloma (figure 1). Overall, the picture is labelled as a stroke in the left posterior cerebral artery territory with a haemorrhagic/infectious component probably related to septic embolus due to Aspergillus. Once the need for neurosurgical intervention was dismissed, antifungal coverage was extended with caspofungin. One week postoperatively, he presented a sudden clinical deterioration with acute respiratory failure requiring invasive mechanical ventilation and intense haemodynamic instability requiring high-dose amine support. Urgent TEE was requested, which showed severe depression of global LV contractility without segmental alterations and normofunctioning prosthetic valves, without definitive data of pulmonary thromboembolism. Finally, exitus was triggered by electromechanical dissociation despite advanced cardiopulmonary resuscitation measures.

Subsequent analysis of the valve revealed the presence of a dense, partially thrombosed structure anchored to the prosthetic disc, composed of thick septate and branched mycelia, compatible with aspergilloma. Aspergillus fumigatus grew in the culture of this mass.

DIAGNOSIS
Fungal endocarditis on prosthetic mitral valve, complicated by:
Prosthetic valve block.
Peripheral embolism with acute ischaemia of the right lower limb, requiring urgent embolectomy.
Stroke in left posterior cerebral artery territory of probable septic origin (aspergilloma).
Cardiogenic shock, electromechanical dissociation. Exitus.
