A 62-year-old man presented with staphylococcal endocarditis on a bicuspid aortic valve. A valve ring abscess occurred, and an acute large fistula from the aortic root to the right ventricle appeared, requiring emergency surgical repair. After surgery, a continuous murmur was still present along both sternal borders, and complete heart block necessitated a dual-chamber pacemaker. During the following 6 months, the continuous murmur became more intense, and an aortic insufficiency murmur appeared. The surgical repair had involved placement of a low-profile mechanical aortic valve prosthesis. Noninvasive follow-up confirmed an enlarging aorta–to–right ventricle communication, along with perivalvular aortic insufficiency. The patient also developed signs and symptoms of biventricular heart failure. An ascending aortogram (Fig 1⇓) revealed contrast medium filling both ventricular chambers. Coronary angiography revealed that a previously small mycotic aneurysm of the distal left main coronary artery had enlarged (Fig 2⇓). A significant left-to-right blood flow shunt at the ventricular level was also confirmed by oxygen content data. Repeat surgical repair involved a repeat aortic valve replacement and closure of the aorta–to–right ventricular fistula. The mycotic aneurysm was primarily ligated. The patient continues to do well.
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
Circulation encourages readers to submit cardiovascular images to Dr Hugh A. McAllister, Jr, St Luke’s Episcopal Hospital and Texas Heart Institute, 6720 Bertner, MC 4-265, Houston, TX 77030.
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