Fatal Prosthetic Valve Endocarditis After Transcatheter Tricuspid Valve Replacement

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  Visual Summary. Timeline of the Clinical Course and Diagnostic Journey, from Baseline Assessment and TTVR (Day 0), Through an In-Hospital Course Complicated by Complete Heart Block Requiring Permanent Pacemaker Implantation (Day 1-6), to Clinical Improvement at 1 and 3 Months, Sudden Death at Approximately 6 Months, and the Subsequent Diagnostic Pathway Initial certification by the general practitioner attributed death to congestive heart failure, followed by coroner's postmortem attribution to coronary artery disease, with specialist cardiac autopsy ultimately establishing PVE. CS = clinical summary; CFS = clinical frailty score; GP = general practitioner; KCCQ = Kansas City Cardiomyopathy Questionnaire; MG = mean gradient; OS = overall summary; PPM = permanent pacemaker; PVE = prosthetic valve endocarditis; TR = tricuspid regurgitation; TTVR = transcatheter tricuspid valve replacement.

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  Figure 1. Baseline Echocardiography, Procedural Fluoroscopy, and Postprocedural Imaging (A) Preprocedural transthoracic echocardiography demonstrating severe tricuspid regurgitation with a free-flow central jet secondary to annular dilatation (4.6 cm). The right ventricle is dilated with impaired systolic function (tricuspid annular plane systolic excursion 1.2 cm; fractional area change 22%). (B) Transthoracic echocardiography at 1 month demonstrating a well-seated Cardiovalve prosthesis with trace residual tricuspid regurgitation and a mean gradient of 3.5 mm Hg. (C) Fluoroscopic image during deployment showing the Cardiovalve delivery system positioned at the tricuspid annulus via right femoral venous access. (D) Fluoroscopic image post-deployment confirming satisfactory positioning of the Cardiovalve prosthesis at the tricuspid annulus.

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  Figure 2. Postmortem Pathology: Prosthetic Valve Endocarditis with Myocardial Microabscesses (A) Gross pathologic specimen of the Cardiovalve prosthesis demonstrating severe prosthetic valve endocarditis with extensive vegetations and multiple irregular, friable masses along the leaflet free edges and coaptation surfaces, projecting into the central orifice, with marked disruption of prosthetic valve architecture. (B) Hematoxylin-eosin–stained section of left ventricular myocardium demonstrating a microabscess characterized by central suppurative necrosis with dense neutrophilic infiltration, bacterial colonies, and disruption of surrounding myocardial fibers, consistent with diffuse coronary septic microembolization.