An aortic root abscess mimic identified by multi-disciplinary imaging review: a case report.

Background: While echocardiography and cardiac positron emission tomography (PET) can aid in the diagnosis of prosthetic valve endocarditis (PVE), post-operative changes can lead to false-positive imaging findings. We report a case of a patient with an aortic valve prosthesis with remnant BioGlue deposits mimicking a para-valvular abscess on imaging in the setting of suspected PVE.

Case summary: A 67-year-old man presented with 2 days of fever, chills, and altered mentation. He had a history of two prior aortic root replacements-19 and 4 years prior to his presentation. He had blood cultures that were persistently positive for Pseudomonas aeruginosa. Initial transoesophageal echocardiogram (TEE) was notable for a thickening of the posterior aortic root thought to be consistent with post-surgical changes. Cardiac PET showed significant uptake around the prosthetic aortic valve, concerning for a para-valvular abscess. However, given the patient's high risk for re-do surgery, clearance of blood cultures, and preserved valve function, our multi-disciplinary endocarditis team (MET) recommended non-surgical management and close follow-up. After 6 weeks of appropriate antibiotics, a TEE demonstrated concern for an evolving para-valvular abscess. The MET performed extensive review of his prior surgical interventions and cardiac imaging, revealing the previous use of surgical BioGlue and stability in the aortic root on imaging, consistent with non-infectious post-surgical changes, and conservative management was recommended.

Discussion: Thorough review of prior interventions and serial imaging in patients with suspected PVE through a multi-disciplinary team approach is essential in elucidating the complete, often complex, clinical picture and recommending the most appropriate management.