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\begin{document}

\title{A combination of severe complications in a case of infective
endocarditis: Dehiscence of prosthetic aortic valve, aortic dissection,
pseudoaneurysm and hematoma causing right ventricular collapse}



\author[1]{Mehmet Sonsöz}%
\author[1]{Ilyas Cetin}%
\author[1]{Duygu Inan}%
\author[1]{alev kılıçgedik}%
\author[1]{Yelda Saltan Ozates}%
\author[1]{Mehmed Yanartas}%
\author[1]{Nihan Kayalar}%
\affil[1]{Turkiye Cumhuriyeti Saglik Bakanligi}%


\vspace{-1em}



  
  \date{May 24, 2024}


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\selectlanguage{english}
\begin{abstract}
Prosthetic valve endocarditis with mechanical complications causing
pulmonary edema is fatal, therefore it needs to be diagnosed early and
should be treated surgically in emergency setting. Transesophageal
echocardiogram is crucial for recognizing the mechanical complications,
which can be encountered on daily practice, but the coexistence of
complications occurring on different mechanism is rather uncommon.
Herein, we report a 21-year-old gentleman presenting with acute heart
failure, whose imaging tests showed a combination of dehiscence of
mechanical aortic valve prosthesis, aortic dissection, pseudoaneurysm
and hematoma causing right ventricular collapse.%
\end{abstract}%



\sloppy


A combination of severe complications in a case of infective
endocarditis: Dehiscence of prosthetic aortic valve, aortic dissection,
pseudoaneurysm and hematoma causing right ventricular collapse

Very severe complications of infective endocarditis Mehmet Rasih
Sonsoz\textsuperscript{1}, Ilyas Cetin\textsuperscript{1}, Duygu
Inan\textsuperscript{1}, Alev Kilicgedik\textsuperscript{1}, Yelda
Saltan Ozates\textsuperscript{1}, Mehmed Yanartas\textsuperscript{2},
Nihan Kayalar\textsuperscript{2}

\textsuperscript{1}Department of Cardiology, Basaksehir Cam \& Sakura
City Hospital, Istanbul, Turkey

\textsuperscript{2}Department of Cardiovascular Surgery, Basaksehir Cam
\& Sakura City Hospital, Istanbul, Turkey

\textbf{Corresponding Author:}

Mehmet Rasih Sonsoz, MD Department of Cardiology, Basaksehir Cam \&
Sakura City Hospital, Basaksehir Olimpiyat Boulevard, 34480, Istanbul,
Turkey Tel: +90-212-9096000 / 21311 Email: mrsonsoz@gmail.com

\textbf{Keywords:} acute aortic dissection, infective endocarditis,
mechanical prosthesis, pseudoaneurysm

\textbf{Consent:} ~The author/s confirm that written consent for
submission and publication of this case report including image(s) and
associated text has been obtained from the patient in line with COPE
guidance.

\textbf{Conflict of interest:} ~none declared

\textbf{Abstract}

Prosthetic valve endocarditis with mechanical complications causing
pulmonary edema is fatal, therefore it needs to be diagnosed early and
should be treated surgically in emergency setting. Transesophageal
echocardiogram is crucial for recognizing the mechanical complications,
which can be encountered on daily practice, but the coexistence of
complications occurring on different mechanism is rather uncommon.
Herein, we report a 21-year-old gentleman presenting with acute heart
failure, whose imaging tests showed a combination of dehiscence of
mechanical aortic valve prosthesis, aortic dissection, pseudoaneurysm
and hematoma causing right ventricular collapse.

A 21-year-old gentleman presented to emergency department in our
hospital with dyspnea, fatigue in April 2022. His medical history
included implantation of mechanical aortic valve prosthesis in February
2022 due to infective endocarditis caused by methicillin-resistant
staphylococcus aureus. He was discharged after 6 weeks of antibiotic
regimen at the end of the March 2022. On admission, he was in New York
Heart Association class IV. He had a temperature of 37.6\selectlanguage{ngerman}° C, a pulse
rate of 107 beats/minute, a respiratory rate of 24 breaths/min, and a
blood pressure of 105/65 mmHg. Physical examination revealed 4/6
systolic murmur on all cardiac auscultation sites, left-sided S4,
tachypnea, bibasilar crackles and jugular venous distention. His
electrocardiogram showed sinus tachycardia. Chest x-ray demonstrated
increased cardio-thoracic index and interstitial pulmonary edema with
pleural effusions. Complete blood count demonstrated severe anemia with
a hemoglobin level of 10.7 g/dl. The white blood cell count and platelet
count were normal. High sensitivity C-reactive protein was 208 mg/L,
procalcitonin was 1.43 ng/mL. Kidney function tests demonstrated
elevated levels of creatinine 1.9 mg/dL. Additional test results
included pro-BNP 11626pg/mL and high-sensitivity troponin T 856 pg/mL.
Transthoracic and transesophageal echocardiogram disclosed normal left
ventricular systolic function, dehiscence of aortic prosthesis, severe
paravalvular regurgitation, pseudoaneurysm of sinus Valsalva, image of
dissection flap and a round, heterogenous mass (75 x 55 mm) consistent
with hematoma causing obstruction to the right ventricular inflow
(Figure A -- D; Video 1 - 3). Contrast enhanced thorax CT confirmed the
aortic dissection, pseudoaneurysm of the sinus Valsalva and hematoma
inside it (Figure E - I). Ceftazidime 2x2 g/day, vancomycin 1g/day and
gentamicin 2 x 160 mg/day were initiated. Under general anesthesia, he
underwent excision of the aortic prosthesis, repair of the
pseudoaneurysm with a pericardial patch and construction of the
neoannulus. A 21 mm Sorin conduit with mechanical prosthesis was
implanted. He was extubated next day, and was admitted to the ward in
order to receive the antibiotics for 6 weeks. His blood cultures
remained sterile.

This case illustrates the importance of prompt imaging in a patient with
prosthetic valve and acute heart failure for the diagnosis and treatment
of mechanical complication of prosthetic valve endocarditis.
Transesophageal echocardiography was necessary for the recognition of
local complications, and contrast enhanced CT contributed to delineating
the complex anatomy around the prosthetic valve. As 2015 ESC guidelines
for the management of infective endocarditis states\textsuperscript{1},
surgery is indicated at emergency setting if the patient has infective
endocarditis with severe regurgitation, obstruction or fistula causing
refractory pulmonary edema or cardiogenic shock. With prompt diagnosis
and surgery, the clinical status of the patient was stabilized.

\textbf{Author contributions}

MRS, IC and YSO were responsible for managing the patient along with
cardiologists-in-charge and contributed to manuscript preparation. AK
and DI performed echocardiography, contributed to concept and data
interpretation of the article. NK and MY performed the surgery and
helped in manuscript preparation.

\textbf{References}

1. Habib G, Lancellotti P, Antunes MJ, et al . 2015 ESC Guidelines for
the management of infective endocarditis: The Task Force for the
Management of Infective Endocarditis of the European Society of
Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic
Surgery (EACTS), the European Association of Nuclear Medicine (EANM).
Eur Heart J 2015;36:3075-3128

\textbf{Figure Legends}

\emph{Panel A.} Apical 5-chamber view demonstrating both severe aortic
regurgitation and turbulent tricuspid inflow caused by the obstruction
of the hematoma. Panel B - D. Transesophageal echocardiogram in
midesophageal view demonstrating dehiscence of prosthetic aortic valve,
large pseudoaneurysm of noncoronary sinus of Valsalva (asterisk). Denote
how the hematoma obstructs the tricuspid inflow (sharp sign). Panel E.
Contrast-enhanced cardiac computed tomography confirms the hematoma
causing right atrial collapse. Panel F. The flap in ascending aorta
indicates aortic dissection (black arrow). Panel G. Coronal axis of CT
scan shows the pseudoaneurysm and hematoma originating from sinus
Valsalva (sharp sign). Panel H. Coronal axis of CT scan shows the
pseudoaneurysm and hematoma collapsing the right ventricle. Panel I. 3D
volume rendering of the CT scan makes the pseudoaneurysm more visible
(sharp sign). Ao: aorta; LA: left atrium; LV: left ventricle; RV: right
ventricle

\textbf{Supplementary Data}

\textbf{Video 1:} Transesophageal four-chamber view demonstrating a
large, cystic mass compatible with hematoma, collapsing right atrial
free wall.

\textbf{Video 2:} Transesophageal short-axis view demonstrating
dehiscence of the prosthetic aortic valve

\textbf{Video 3:} Transesophageal long-axis view demonstrating severe
paravalvular aortic regurgitation

Ao: aorta; H: hematoma; LA: left atrium; LV: left ventricle; RV: right
ventricle

\textbf{Hosted file}

\verb`Figure.pptx`  available at \url{https://authorea.com/users/481386/articles/568463-a-combination-of-severe-complications-in-a-case-of-infective-endocarditis-dehiscence-of-prosthetic-aortic-valve-aortic-dissection-pseudoaneurysm-and-hematoma-causing-right-ventricular-collapse}

\selectlanguage{english}
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