Background: Infective endocarditis (IE) refers to inflammation of the endocardium, which is the inner layer of the heart. One of the most significant risk factors for developing IE is bioprosthetic valves within the heart. IE can lead to formation of vegetations on the surfaces of heart valves, making treatment difficult with antibiotics alone, often requiring surgery. Although IE can be treated with surgery or antibiotics, the presence of bioprosthetic valves can lead to recurrence of infection. Recurrence can cause several different complications including pseudoaneurysms of the mitral-aortic intervalvular fibrosa (MAIVF).

Case presentation: A 73-year-old male with a history of bicuspid aortic valve requiring several aortic valve replacements for IE presented to a university hospital with altered mental status and hypotension to 79/50. The patient developed severe sepsis with blood cultures growing Streptococcus dysgalactiae. Given the patient’s extensive history of IE, transesophageal echocardiogram (TEE) was done to rule out recurrence of infection. TEE showed pseudoaneurysm of the mitral-aortic intervalvular fibrosa (MAIVF). Cardiothoracic surgery was consulted for possible surgical intervention given this finding in the setting of recurrent prosthetic valve endocarditis (PVE) but ultimately decided that the patient was a poor surgical candidate given his extensive history of cardiac surgeries. The patient was stabilized with antibiotics and fluid resuscitation and was discharged with a course of antibiotics followed by lifelong prophylactic antibiotic therapy.

Conclusion: This case highlights the life-threatening sequelae of PVE. Pseudoaneurysm of the MAIVF is a rare complication of PVE that occurs from PVE itself or surgery to the aortic or mitral valves. Providers should be aware of the importance of early detection of these findings with close follow up and imaging with modalities like TEE or cardiac computed tomography angiography (CTA) to see if surgical interventions can be pursued before further complications arise.

Cardiac Surgery, Endocarditis, Pseudoaneurysm