Mr. Q, a 50-year-old Caucasian, was referred for evaluation of fatigue that had begun three months earlier. During the past two weeks, he had also had low-grade fever and chills. Five months before his visit with us, he had undergone valve replacement for aortic stenosis associated with a congenital bicuspid aortic valve. His postoperative course was complicated by the development of complete heart block, for which he underwent placement of an atrioventricular sequential pacemaker.


Clinical examination revealed a temperature of 101°F and BP 130/60 mm Hg. On auscultation of the precordium, a prosthetic second heart sound with a grade 2/6 systolic murmur and a soft early diastolic murmur in the aortic area were heard.

Because of the patient’s surgical history, blood was drawn for cultures. Meanwhile, a transthoracic echocardiogram showed the presence of aortic regurgitation with a paravalvular leak. A transesophageal echocardiogram (TEE) revealed decreased mobility of the aortic disk valve and a mobile vegetation associated with an increased instantaneous peak gradient of 61 mm Hg. An aortic ring abscess was also observed.

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Based on a working diagnosis of endocarditis, we started Mr. Q on empiric treatment with ceftriaxone and vancomycin. In order of frequency, the most likely causes of endocarditis are coagulase-negative staphylococci, Staphylococcus aureus, fastidious organisms responsible for culture-negative disease, and fungi. Other diagnostic possibilities being considered were infection of a pacemaker lead and sepsis due to unrelated causes, such as UTI or pneumonia.

Mr. Q soon developed signs of heart failure and was taken to the operating room for emergent valve replacement and debridement. The surgeon found a partial dehiscence of the valve along with an abscess cavity between the anterior mitral leaflet and the aortic root.