Infective endocarditis (IE) refers to the colonization of cardiac valve endocardium by virulent microorganisms. It is the fourth leading cause of life-threatening infectious disease syndrome, if not efficiently diagnosed and treated. The three most common causes of IE on native valves (from the most to the least frequent) are Staphylococci, Streptococci and Enterococci.
Enterococcus related IE are often associated to endoscopic procedures involving the digestive tract.
The most remarkable structural complications associated with IE are: cusp or leaflet rupture, perforation, aneurysm/pseudoaneurysm, fistula, abscess, embolization. The usual final consequences of these lesions are severe valve regurgitation and heart failure.A 74 years old male patient with no history of heart disease, presented to the hospital with orthopnoea and periferal edema, consistent with acute heart failure.Few months before he underwent a routine colonscopy. Transthoracic echocardiography revealed a mildly reduced ejection fraction and the presence of a little, mobile mass on the aortic valve, suggestive of vegetation, associated with a severe aortic regurgitation. The diagnosis was confirmed thanks to a transesophageal echocardiogram that represents the technique of choice for the diagnosis of endocarditis and for detecting eventual perivalvular extention; it documented the presence of an endocarditic vegetation protruting in the LVOT, complicated by a pseudoaneurysm, identified as a pulsatile perivalvular echo free-space with colour doppler flow inside. Successively, a specific antibiotic therapy was started because of the positivity of blood cultures for Enterococcus Faecalis. After performing a thoracic computed tomography that showed the presence of “plus image" at the level of aortic valvular plane, particularly between the right coronary and non-coronary cusp, consistent firstly with a pseudoaneurysm, the patient underwent urgent cardiac surgery with the removal of the vegetations and the implantion of an aortic valve bioprosthesis after the apposition of bovine pericardial patches for repairing aortic wall’s lacerations. A post-operative transesophageal echocardiogram revealed a good result with a mild paravalvular leak.
Pseudoaneurysm and severe valvular regurgitation are among the major causes of acute heart failure in the setting of infective endocarditis. In such cases, surgery should be considered to decrease mortality.