PMC8289619_01
Microscopy. Gram-stain smear (1000x magnification) showing gram-positive (violet) cocci in chains consistent with Lactococcus garvieae.
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Subsequently, blood cultures (4/4) grew Lactococcus garvieae (Figure 1). TAVR consistent with vegetation (Figure 5, Video 1). There were no cusp perforations, significant valvular insufficiencies, paravalvular abscess or leaks, nor evidence of valve thrombosis (normal valve hemodynamics by Doppler, plus valve was bioprosthetic and not mechanical, and patient was compliant with chronic anticoagulation).
Electrocardiogram. Initial electrocardiogram revealing atrial fibrillation with fast ventricular response (126 bpm). There were no new ST-segment changes suggestive of acute ischemia.
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Initial electrocardiogram (Figure 2) showed afib with a fast ventricular response (FVR), without chest pain or new ST-segment changes compelling for an acute coronary syndrome.
Chest X-ray (CXR): there are mildly increased interstitial markings (chronic in character), cardiomegaly, and no evidence of consolidation or pleural effusion. Loop monitor can be visualized in the CXR at the left lower chest wall as well as a valve-in-valve TAVR (red arrow).
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Chest X-ray (Figure 3) and head CT scan were negative for acute pathologies.
Transthoracic echocardiogram parasternal long-axis view. (a) Valve-in-valve TAVR (red arrow) with some artifacts causing suboptimal resolution and visualization of the bioprosthesis, yet no overt large vegetations were detected. No pericardial effusion present and systolic function was preserved (55%). (b) Diastolic frame showing no evidence of significant regurgitation by color Doppler. RV: right ventricle; LV: left ventricle; LA: left atrium.
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Transthoracic echocardiogram (TTE) revealed no prosthetic aortic valve dysfunction nor large vegetations (Figure 4).
Transesophageal echocardiogram (TEE) midesophageal views (Video 1). Various frames of TEE images showing an elongated and oscillating echogenic structure (red arrow) attached to the right coronary cusp leaflet of the valve-in-valve TAVR (blue arrow) consistent with an infective endocarditis vegetation (measuring 0.7 cm). No significant insufficiency or paravalvular extension of infection was detected. No evidence in favor of valvular thrombosis. The other native valves (especially the mitral valve) had no vegetations. LA: left atrium; Ao: ascending aorta.
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TAVR consistent with vegetation (Figure 5, Video 1). There were no cusp perforations, significant valvular insufficiencies, paravalvular abscess or leaks, nor evidence of valve thrombosis (normal valve hemodynamics by Doppler, plus valve was bioprosthetic and not mechanical, and patient was compliant with chronic anticoagulation).