What question did this study set out to answer?

To illustrate the complexities and varying outcomes of surgical intervention in severe infective endocarditis cases.

July 20, 2026Journal of Cardiothoracic Surgery0 citationsOpen Access

Complex infective endocarditis with perivalvular abscess and fistulation: two high-risk cases requiring extensive reconstruction and valve replacement

MLMarco Lizwan EWEdwin Yosef Widjaja SESee Hooi Ewe

Key Points

To illustrate the complexities and varying outcomes of surgical intervention in severe infective endocarditis cases.
Two case reports of patients with aortic valve endocarditis and aortic root abscess.
Patients underwent extensive surgical procedures including valve replacement and fistula repair.
Postoperative management included antibiotics and monitoring for complications.
First patient had transient renal and hepatic dysfunction, then recovered post-surgery.
Second patient showed initial repair success but later developed severe complications leading to death.
Findings indicate the risks associated with complex endocarditis surgical interventions.

Abstract

Abstract Background Infective endocarditis (IE) complicated by aortic root abscess, fistulation and multivalve involvement is rare but carries high mortality. Fistulation from the left ventricular outflow tract (LVOT) to the right atrium (RA) represents an exceptionally uncommon sequela due to extensive perivalvular tissue destruction. Early surgical intervention remains crucial, but postoperative outcomes vary widely depending on host factors, organism control and the feasibility of durable reconstruction. Case presentation We report two cases of severe aortic valve endocarditis with aortic root abscess and acquired LVOT-RA fistula. The first patient had native-valve Streptococcus mitis endocarditis and underwent aortic and tricuspid valve replacement with double CardioCel patch repair of the fistula. He recovered after transient renal and hepatic dysfunction and completed six weeks of intravenous ceftriaxone. The second patient had prosthetic aortic valve endocarditis with aortomitral curtain destruction, pseudoaneurysm, severe malnutrition, and tricuspid involvement. He underwent redo sternotomy, aortomitral curtain reconstruction, double patch fistula repair, and triple bioprosthetic valve replacement. Although the initial repair was technically satisfactory, he later developed severe mitral paravalvular regurgitation with recurrent Staphylococcus haemolyticus bacteremia and died after deterioration with sepsis and multiorgan dysfunction. Conclusion These cases illustrate the range of outcomes after complex endocarditis surgery. Patch-based reconstruction may be appropriate when radical debridement leaves sufficient tissue for secure prosthetic seating, whereas extensive prosthetic infection, malnutrition, recurrent bacteremia, and tissue friability increase the risk of late mechanical failure.

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