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Transesophageal echocardiography showing a hypodense structure near the bifurcation of the pulmonary artery with a transversal diameter of approximately 14 mm, consistent with a thrombus or a vegetation (
arrow
).
(B)
Fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET-CT) showing high activity in the right ventricular outflow tract (RVOT) adherent to the sternum (
arrow
).
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Preoperative transesophageal echocardiography showed a hypodense structure close to the bifurcation of the pulmonary artery (transverse diameter of ~14 mm), consistent with a thrombus or vegetation ( Fig. 1A ) causing obstruction ( V max  > 4 m/s). Positron emission tomography/computed tomography (PET-CT) showed pathological tracer uptake in the homograft region ( Fig. 1B ). 
Schematic drawing of cardiopulmonary bypass connection. ECC, extracorporeal circulation.
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Cardiopulmonary bypass (CPB) connection is depicted in Fig. 2 .
(
A
) Explanted homograft and septic thrombus. (
B
) Reconstructed right ventricular outflow tract (surgeons' perspective). (
C
) Mycotic colonization inside the explanted tissue (Grocott's staining Obj. x10).
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Explanted tissue is depicted in Fig. 3A . Freestyle root bioprosthesis (Medtronic plc., Dublin, Ireland) was implanted into the RVOT ( Fig. 3B ). Histology of the explanted homograft showed an active as well as chronic granulating inflammation with extensive mycotic colonization ( Fig. 3C ).
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