Fig. 3

A 65-year-old man with a previous history of bioprosthetic aortic valve replacement and ascending aorta homograft repair presents with fever and sepsis. (a) A still TOE image short axis to the aortic valve demonstrates an echodensity (curved arrow) arising from the non-coronary cusp (*) of the prosthetic aortic valve; this echodensity demonstrated mobility on real-time cine imaging consistent with a vegetation. (b) A 3-chamber TOE still image re-demonstrates the prosthetic aortic valve vegetation (curved arrow), with echogenic soft tissue thickening of the posterior aortic valve annulus (straight arrow), concerning for paravalvular abscess. (c) An axial ECG-gated cardiac CT angiogram demonstrates a large aortic root abscess (dashed line) with a small pseudoaneurysm (curved arrow) arising from the right sinus of Valsalva, adjacent to the origin of the right coronary artery (*). (d) A coronal MPR from the CT re-demonstrates the vegetation on the non-coronary cusp of the bioprosthetic valve (arrow), with further delineation of the aortic root abscess (dashed line). The patient underwent a repeat aortic valve and ascending aorta homograft replacement. Tissue culture of the removed bioprosthetic valve grew coagulase-negative Staphylococcus and E. faecalis. Ao = ascending aorta; LA = left atrium; RA = right atrium; PA = pulmonary artery; RVOT = right ventricular outflow tract