Cardiac Magnetic Resonance Imaging Identifies the Elusive Perivalvular Abscess
A 51-year-old man with known bicuspid aortic valve disease presented with a 3-day history of fever. Examination revealed mixed aortic valve disease (confirmed by transthoracic echocardiography) and microscopic hematuria. He was given intravenous antibiotics, and blood cultures confirmed Staphylococcus aureus infection.
The patient subsequently developed first-degree heart block (Figure 1) but both transthoracic echocardiography (Movie I) and transesophageal echocardiography (Movie II) did not identify the clinically suspected perivalvular abscess. His chest x-ray examination was unremarkable except for left ventricular dilatation (Figure 2). However, cardiovascular magnetic resonance (CMR) imaging demonstrated a structural abnormality in the basal septum with surrounding late enhancement after gadolinium administration, which is consistent with a septal abscess (Figure 3).
Surgical debridement was initially deferred pending control of the active infection. When the patient later developed transient complete heart block (Figure 4), reassessment with transesophageal echocardiography still did not demonstrate a septal abscess; however, CMR showed clearly identifiable aortic perivalvular abscess (Figure 5 and Movie III). Similarly, CMR with delayed hyperenhancement in the short-axis plane showed an area of hyperenhancement (representing walls of the abscess) and a surrounding area of no signal (abscess cavity itself) (Figure 6). Successful abscess debridement and aortic valve replacement (Figure 7) were undertaken, and histology confirmed a noncoronary cusp abscess with acute inflammatory changes within both aortic valve leaflets (Figure 8).
This is the first reported case of perivalvular abscess identification via CMR imaging. It reflects the clinical utility of this imaging modality with its high-quality spatial resolution. Echocardiography is the established imaging modality for the diagnosis of perivalvular abscess, with transesophageal echocardiography (80% sensitivity) being more sensitive than transthoracic echocardiography (38% sensitivity).1,2 In this case, however, echocardiographic examinations (including transesophageal echocardiography) failed to demonstrate the suspected abscess. In contrast, CMR confirmed the presence of the abscess in its early stages and provided useful images for the surgeon when debridement was undertaken. Hence, CMR warrants consideration in the clinical evaluation of suspected cardiac abscess.
We would like to thank the staff of the Radiology Department at the Queen Elizabeth Hospital, Adelaide, Australia and the staff of the Cardiothoracic Surgical Department at the Royal Adelaide Hospital, Adelaide, Australia for their help with this article. Dr Beltrame is a National Heart Foundation of Australia Research Fellow.
The online-only Data Supplement, which contains Movies I through III, can be found at http://circ.ahajournals.org/cgi/content/full/118/1/e1/DC1.
Choussat R, Thomas D, Isnard R, Michel PL, Iung B, Hanania G, Mathieu P, David M, du Roy de Chaumaray T, De Gevigney G, Le Breton H, Logeais Y, Pierre-Justin E, de Riberolles C, Morvan Y, Bischoff N. Perivalvular abscesses associated with endocarditis: clinical features and prognostic factors of overall survival in a series of 233 cases. Perivalvular Abscesses French Multicentre Study. Eur Heart J. 1999; 20: 232–241.