Case
We report the case of a 65-year-old man with a history of severe aortic stenosis and aortic prosthetic valve replacement. Pre-surgical coronary angiography showed no significant obstructions, and other comorbidities were discarded. The patient recovered without complications and was discharged home with anticoagulant treatment. One month after surgery, he arrived at the emergency department complaining of sudden oppressive retrosternal chest pain and dyspnea. On physical examination, his heart rate was 74 beats per minute, he was found to be diaphoretic, hypotensive, and tachypneic with 96% oxygen saturation. Thoracic examination revealed no rales and prosthetic valve sounds without murmurs. His leukocyte, glucose, troponin, and B-type natriuretic peptide (BNP) levels were 8.5x109/L, 143g/dL, 120ng/ml and 659pg/mL, respectively. The initial electrocardiogram showed anterolateral ST-segment elevation myocardial infarction (STEMI). Emergency coronariography was performed, revealing proximal left anterior descending (LAD) artery embolic occlusion, and coronary balloon angioplasty was successfully performed. (Figure 1)
During recovery, the patient presented with fever; blood cultures were taken, and empirical vancomycin was initiated. Transthoracic echocardiography (TTE) showed normal prosthetic function and no vegetation. Blood cultures were negative, and clinical evolution was satisfactory, so he was discharged home. The patient was readmitted to the emergency department three weeks later with fever, cardiogenic shock, and complete atrioventricular block, so a temporal pacemaker was placed. Upon physical examination, a new aortic systolic murmur was auscultated without prosthetic click sounds. Urgent TTE revealed 14 x 15 mm vegetation at the prosthetic aortic valve. Septic and cardiogenic shock were diagnosed and attributed to infective endocarditis. The patient experienced cardiac arrest and died a few hours later, despite aggressive management. The postmortem pathology report confirmedĀ Aspergillus ssp , prosthetic aortic valve endocarditis, and anterolateral myocardial infarction. (Figure 2)