CASE PRESENTATION
The 76-year-old women had undergone aortic valve replacement using a bioprosthetic valve (CEP Magna 21 mm: Edwards LifeSciences, Irvine CA) due to aortic valve stenosis. Postoperatively, she developed complete atrioventricular block and required pacemaker implantation. She had not suffered from heart failures or infections during her outpatient follow-up after discharge, but visited her outpatient clinics two years later due to fever and general fatigue. Significant elevations of inflammatory markers were observed (WBC18.3x103/μl and CRP 18.6 mg/dl, respectively), and Staphylococcus capitis was detected in her blood cultures. In addition, CT imaging revealed renal infarction and splenic infarction, and aortic valve abscess was suspected on transesophageal echocardiography. The diagnosis of infective endocarditis was made, and a 6-week course of vancomycin successfully resolved the infection. She was transferred to our hospital for surgical treatment to remove aortic annulus abscess. Upon admission, her height, body weight and body temperature were 149cm and 53kg, and 36.4°C, respectively. Her blood pressure was 92/43mmHg with a regular pulse of 60 beats/min. Inflammatory markers had normalized (WBC7.90x103/μl and CRP 0.23mg/dl, respectively). Procalcitonin was negative. Left ventricular ejection fraction was 81%, but aortic valve insufficiency from the same site as suspected abscess cavity around right coronary cusp-non coronary cusp (paravalvular leakage) was observed without apparent vegetations. There was no significant stenosis in the coronary artery, and the right coronary artery (RCA) shared a common opening with the left coronary artery (LCA) that originated from the left coronary cusp (LCC). The RCA ran anteriorly to the aorta between the aorta and the pulmonary artery. An abscess cavity was noted adjacent to the dorsal side of the RCA (#1) (Fig. 1a, 1b).