Increased aortic wall thickness on CT as a sign of prosthetic valve endocarditis

Multimodality imaging in the diagnosis of bioprosthetic aortic valve endocarditis: A case report

Introduction

Prosthetic valve infective endocarditis (PVE) is a diagnostic challenge even in the era of multimodality cardiovascular imaging.

Case presentation

The patient was a 67-year-old male with a three-year history of bioprosthetic aortic valve replacement who presented with persistent fever and negative blood cultures. The initial transthoracic echocardiography revealed a thickened aortic root. An abscess formation was visualized upon subsequent three-dimensional transesophageal echocardiography and positron emission tomography/computerized tomography (PET/CT). The patient underwent an urgent necrotic tissue debridement and a redo Bentall surgery. The real-time polymerase chain reaction of excised tissues was positive for Streptococcus.

Clinical discussion

The diagnosis of PVE and its complications requires the integration of clinical, microbiological, and serial imaging data. Although advanced imaging modalities like PET/CT allow a timely diagnosis and management, their routine use in resource-limited scenarios is difficult.

Conclusion

Multimodality cardiovascular imaging plays an important role in the diagnosis of PVE. Serial echocardiographic and clinical assessments are possible alternatives when the access to advanced cardiovascular imaging modalities is limited.

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Thickening of the aortic wall adjacent to the aortic valve prosthesis can be the early manifestation of aortic root abscess.

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Multimodality imaging is an invaluable asset to ensure timely diagnosis and appropriate management of PVE.

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Serial TTEs and/or TEEs are possible alternatives when the access to advanced cardiovascular imaging modalities is limited.

Aortic valve endocarditis by Actinomyces odontolyticus and Gemella morbillorum oral pathogens

A 56-year-old female with a history of poor dental hygiene and aortic insufficiency status post aortic valve replacement in 2015 presented with chest pain and fevers. She was found to have portal vein thrombosis, colitis, and infective endocarditis with aortic valve thickening. Blood cultures were positive for Actinomyces odontolyticus and Gemella morbillorum. Transesophageal echocardiogram was positive for aortic root thickening. Patient was treated with ceftriaxone and apixaban with full recovery.

Normal Values of the Mitral-Aortic Intervalvular Fibrosa Thickness: A Multimodality Study

Background:

The avascular region of the fibrous body between the mitral and aortic valves, named mitral-aortic intervalvular fibrosa (MAIVF), is often involved in the periaortic diffusion of infective endocarditis (IE), resulting in abscess or pseudoaneurysm formation. The early recognition of these life-threatening complications is of crucial importance, as urgent surgical correction is necessary. In the first stages of the abscess formation, the only sign is an increased thickness of the MAIVF. To the best of our knowledge, normal transesophageal echocardiography (TEE) examination reference values for MAIVF thickness has not yet been established. The aim of the study was to define the normal ranges of MAIVF thickness in a population of healthy adults who underwent a TEE examination.

Materials and Methods:

A population of consecutive adult patients who underwent a TEE examination was enrolled in the study. Measurement was performed in short-axis (SAX) and long-axis (LAX) views. Mean-2 standard deviations (mean-2SDs) and 5%, 10%, 90%, and 95% confidence intervals were evaluated. A comparison with MAIVF thickness in patients affected by aortic IE complicated by abscess formation was performed, and receiver operating characteristic (ROC) curves were constructed to achieve the optimal cutoff value of normality.

Results:

A total of 477 consecutive Caucasian adult patients were enrolled (mean age: 69 years, range: 27–93 years). Mean-2SD MAIVF measurement in SAX view was 0.325 cm (95% confidence interval [CI]: 0.319–0.330 cm) and in LAX view was 0.340 cm (95% CI: 0.334–0.346 cm). Computed tomography–MAIVF mean measurement (±2SD) was 0.237 cm (95% CI: 0.110–0.340 cm). ROC curves showed that a cutoff SAX value measurement of 0.552 (area under the curve [AUC]: 95.2%) had a sensibility of 88.2% and a specificity of 92.4%; a LAX measurement value of 0.623 (AUC: 93.3%) had a sensibility of 82.7% and a specificity of 85.7%. The multivariate analysis showed no significant correlation between MAIVF thickness, age, and sex.

Conclusion:

In healthy patients, MAIVF thickness should not exceed 0.600 cm. Above these values, the suspicion of a periaortic abscess formation should be raised. MAIVF increased thickness may be an early sign of perivalvular diffusion requiring an urgent endocarditis team evaluation.

Surgical decision-making in aortic prosthetic valve endocarditis: the influence of electrocardiogram-gated computed tomography

OBJECTIVES

The aim of this study was to investigate the value of electrocardiogram (ECG)-gated computed tomography (CT) in the surgical decision-making and preoperative evaluation in patients with aortic prosthetic valve endocarditis (PVE).

METHODS

Sixty-eight prosthetic valves in 67 patients with aortic PVE were prospectively evaluated with ECG-gated CT and transoesophageal echocardiography (TEE). Imaging findings considered indications for surgery were as follows: (i) abscess/pseudoaneurysm formation; (ii) prosthetic valve dehiscence; (iii) valve destruction with valvular regurgitation; (iv) large vegetations (>1.5 cm). The coronary arteries were evaluated with ECG-gated CT. Clinical data including surgical reports and mortality data were collected.

RESULTS

Fifty-eight of 68 cases had indication for surgery based on imaging findings (ECG-gated CT/TEE). In 8 of these cases (14%), there was indication for surgery based on CT but not on TEE findings (all had perivalvular pseudoaneurysms). In 11 cases (19%), there was indication for surgery based on TEE but not on CT findings [non-drained abscess (n = 5), prosthetic valve dehiscence (n = 4), large vegetation (n = 1), valve destruction (n = 1)]. In 31 of 32 patients with indication for preoperative coronary angiography, ECG-gated CT coronary angiography was diagnostic. In 1 patient, ECG-gated CT coronary angiography was inconclusive and invasive coronary angiography was performed.

CONCLUSIONS

In patients with aortic PVE, ECG-gated CT provides additional information over TEE regarding perivalvular extension of infection, which can influence surgical decision-making. Furthermore, ECG-gated CT provides a non-invasive coronary angiogram and can in most cases replace invasive coronary angiography in the preoperative evaluation.