Fatal infective endocarditis early after TAVR

A 75-year-old patient who had received Evolut R 34 TAVR prosthesis for severe aortic stenosis 2 months prior, presented for dyspnea, altered mental status and abdominal pain. Three blood cultures sets tested positive for Enterococcus faecalis. Transthoracic echocardiography was limited by a poor acoustic window, prompting for transesophageal echocardiography, which revealed an echo-free gap between the prosthesis and the posterior aortic wall suggesting the possibility of a periprosthetic abscess (Panel A). Cardiac CT found an abscess between the metal structure of the prosthesis and the noncoronary aortic sinus (Panel B, arrow and Panel C, top arrow), as well as filling defects suggesting vegetations at the level of the biological valve and of the metal structure of the prosthesis (Panel C, buttom arrow and Panel D, arrow). Two aortic pseudoaneurysms in relation to the distal extremity of the endoprosthesis’s stent were also present (Panel D and E, arrowhead). Multiorgan CT scans performed as a part of the IE imaging approach revealed multiple recent ischemic lesions in the brain (Panel F), as well as hepatic, splenic and renal infarcts (Panel G). Given the severe neurological deficit caused by the stroke, the patient was not a candidate for surgical prosthesis replacement. During the monitoring, the patient presented worsening of the symptoms and he died on Day 7 of his hospitalization. Our case emphasizes the possibility of a negative outcome after TAVR, as well as the role of imaging in the diagnosis of early infective endocarditis after TAVR.1,2 The case was conducted in accordance with the Declaration of Helsinki, and approved by the Local Ethics Committee. The data underlying this article will be shared on reasonable request to the corresponding author. The authors have no conflicts of interest to declare. The authors received no financial support for the research, authorship, or publication of this article.