PMC8575599_01
Transesophageal echocardiography image acquired prior to TAVR demonstrating thickened aortic valve with significant central aortic regurgitation without evidence of vegetation or perforation.
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TEE showing resolution of infection, and severe, symptomatic, degenerative aortic regurgitation (Figure 1) status post uncomplicated TAVR (Edwards Lifesciences, Irvine, CA) given high surgical risk with postprocedure TTE showing peak and mean gradients of 27 mmHg and 12 mmHg, respectively, across the valve and no perivalvular regurgitation, presented six weeks post-TAVR after a syncopal episode. The patient reported several days of nausea, fevers, dizziness, and malaise.
Transesophageal echocardiography of infected TAVR. (a) Thickened TAVR leaflets (red arrow) and vegetation of the mitral valve (yellow arrow). (b) Thickened TAVR leaflets (red arrow) and vegetation of the aortic cusp (yellow arrow). (c) Vegetations of the tricuspid valve (red arrow) and aortomitral continuity (yellow arrow).
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TAVR, antibiotic therapy was transitioned to vancomycin, gentamycin, and rifampin. TEE was performed on hospital day 3 and demonstrated bulky vegetative material extending from the aortic root to the atrial surface of the anterior mitral leaflet measuring 2.0 x 0.07 cm, as well as small discrete vegetative lesions measuring 0.5 x 0.3 cm and 0.5 x 0.3 cm on the atrial side of the anterior mitral leaflet and ventricular side of the aortic valve, respectively (Figure 2(a)-2(c) and Figure 3), moderate mitral regurgitation, trivial bioprosthetic aortic valve regurgitation, mild bioprosthetic aortic valve stenosis (peak velocity: 3.3 m/s) with moderately thickened leaflets along all three coaptation lines suggestive of vegetations, and mild tricuspid regurgitation.
3D transesophageal echocardiography of infected TAVR showing bulky vegetation on the anterior mitral valve leaflet (arrow).
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TAVR, antibiotic therapy was transitioned to vancomycin, gentamycin, and rifampin. TEE was performed on hospital day 3 and demonstrated bulky vegetative material extending from the aortic root to the atrial surface of the anterior mitral leaflet measuring 2.0 x 0.07 cm, as well as small discrete vegetative lesions measuring 0.5 x 0.3 cm and 0.5 x 0.3 cm on the atrial side of the anterior mitral leaflet and ventricular side of the aortic valve, respectively (Figure 2(a)-2(c) and Figure 3), moderate mitral regurgitation, trivial bioprosthetic aortic valve regurgitation, mild bioprosthetic aortic valve stenosis (peak velocity: 3.3 m/s) with moderately thickened leaflets along all three coaptation lines suggestive of vegetations, and mild tricuspid regurgitation.
Intraoperative view of TAVR showing thickened TAVR leaflets (red arrow) and vegetative material (yellow arrow).
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She was taken for emergent surgery, undergoing TAVR valve explantation (Figure 4), bovine pericardial tissue aortic and porcine bioprosthetic mitral valve replacement, tricuspid valve repair with anterior septal commissuroplasty, ventricular septal defect closure with a bovine pericardial patch, and right ventricular free wall perforation repair, likely a complication from transvenous pacemaker placement versus secondary to recent infarct from septic emboli.