A Mass at Aorto-Mitral Continuity Following Transcatheter Aortic Valve
Implantation That Mimics Infective Endocarditis.
Abstract
Abstract With the increasing number of transcatheter aortic valve
implantations (TAVI) being performed comes a need to better understand
TAVI-associated complications such as infective endocarditis (IE),
leaflet thrombosis, and paravalvular regurgitation. An 83 year-old
women, who had undergone TAVI followed by permanent pacemaker
implantation 3 months before, presented to outpatient clinic with fever
lasting for 5 days. History revealed that fever reached 39°C and was
subsided by the initiation of amoxycillin/clavulinic acid prescribed by
her family physician. Transesophageal echocardiography (TEE) revealed
normal aortic leaflet thickness and motion. A mass at aorto-mitral
continuity in left atrium was detected (Figure 1A, Video 1). The mass
was heterogenous, 8×3 mm in size, and did not have visual
characteristics of vegetation. Mitral valve seemed unaffected. There was
no mitral regurgitation. No paravalvular abscess, pseudoaneurysm, or
fistula was detected. We had confirmed that the mass was not present
before the TAVI after reviewing preprocedural computed tomography (CT)
scan (Figure 1B). There was fluorodeoxyglucose uptake around TAV and
permanent pacemaker leads in positron emission computed tomography
(Figure 1C). With the fever early after TAVI and a suspicious mass
adjacent to TAV, we decided to treat the patient as “possible IE”
according to modified Duke criteria. A 6-week therapy of vancomycine
plus rifampin accompanied by 2-week therapy of gentamycine was
initiated. The first set of blood cultures turned out to be negative.
Second set of blood cultures were also negative at the second week of
hospitalization. TEE was repeated at the 3rd and 5th weeks and showed
identical findings to the first TEE (Figure 2, Video 2-3). Clinical
condition of the patient was very good. She did not develop fever after
hospitalization. The patient was discharged uneventfully after 6 weeks
of antibiotic therapy. We had concluded that the mass could be thrombus
in origin. After 6 motnhs of warfarin plus clopidogrel therapy control
TEE revealed that the mass at aorto-mitral continuity had disappeared,
mitral valve was normal, TAV was normal with similar valvular gradient
and had trivial paravalvular regurgitation identical to initial
examinations (Figure 2, Video 4). There was no finding of paravalvular
abscess, pseudoaneurysm, or fistula. The patient was still asymptomatic
with good functional capacity and TTE showed normal valvular function at
1-year followup of TAVI.