Aortic root abscess occurs frequently in aortic prosthetic valve infective endocarditis. The present echocardiography report documents a ruptured abscess that led to a direct communication between the left ventricular outflow tract and the left atrium confirmed by real-time (color flow) Doppler imaging

Estioko, Manuel R.

Fisher, Edward A.

Goldman, Martin E.

Stern, Eric H.

Elsevier - Publisher Connector 

222 JACC Vol. 10, No. I
July 1987:222-4
Left Ventricular to Left Atrial Communication Secondary to a
Paraaortic Abscess: Color Flow Doppler Documentation
EDWARD A. FISHER, MD, MANUEL R. ESTIOKO , MD, FACC, ERIC H. STERN, MD, FACC,
MARTIN E. GOLDMAN, MD, FACC
New York, New York
Aortic root abscess occurs frequently in aortic prosthetic
valve infective endocarditis. The present echocardio-
graphic report documents a ruptured abscess that led
to a direct communication between the left ventricular
Aortic root abscess, a serious complication of infective en-
docarditis, has been reported in up to 30% of patients with
native valve endocarditis (1) and 100% of patients with
prosthetic valve endocarditis (2). Though previously diag-
nosed only at surgery or autopsy, aortic root abscess has
recently been detected with two-dimensional echocardiog-
raphy (3,4). This report describes a hitherto unrecognized
complication of aortic root abscess: a left ventricular to left
atrial communication that was accurately diagnosed by two-
dimensional echocardiography and color flow Doppler im-
aging .
Case Report
Clinical features. A 33 year old female intravenous drug
abuser was hospitalized in February 1986 with fever and
congestive heart failure. Blood cultures were positive for
Streptococcus viridans. An echocardiogram revealed a large
aortic valve vegetation and significant aortic regurgitation.
Because of progressive heart failure , the patient underwent
aortic valve replacement with a Carpentier-Edwards porcine
heterograft. A 1.5 em? area of necrotic myocardium beneath
the left coronary leaflet was excised surgically. After 4 lf2
weeks of intravenous penicillin therapy, the patient left the
hospital against medical advice only to present 2 weeks later
with fever and dyspnea .
From the Division of Cardiology, Department of Medicine of the Mount
Sinai Medical Center , Mount Sinai School of Medicine, New York and
the Department of Medicine, Lenox Hill Hospital, New York , New York.
Manuscript received July 31, 1986; revised manuscript received Sep-
tember 29, 1986 , accepted November 17, 1986 .
Address for reprints: Martin Goldman , MD, Division of Cardiology,
Mount Sinai Hospital, One Gustave L. Levy Place , New York, New York
10029 .
©1987 by the American College of Cardiology
outflow tract and the left atrium confirmed by real-time
(color flow) Doppler imaging.
(J Am Coli CardioI1987;10:222-4)
On examination , the patient was thin and cachectic with
a temperature of 103°F, a pulse of 110 beatslmin, respiratory
rate of 28/min and blood pressure of 104/60 mm Hg. There
was mild jugular venous distension ; the lungs were clear.
The cardiac examination was significant for a normal first
heart sound, single second and absent third , a grade 4/6
harsh systolic murmur at the apex and second left intercostal
space and a 2/6 early decrescendo diastolic murmur along
the left sternal border. There was mild hepatomegaly . There
was moderate digital clubbing, but no peripheral edema or
embolic stigmata. Chest X-ray film revealed cardiomegaly
with moderate pulmonary vascular congestion. The electro-
cardiogram (ECO) showed sinus tachycardia with nonspe-
cific ST-T wave abnormalities. The white blood cell count
was 9,100 mrrr' with 67 segmented polymorphonuclear cells,
four band forms and 29 lymphocytes. Multiple blood cul-
tures were positive for Streptococcus viridans. Intravenous
penicillin, digitalis , furosemide and hydralazine were be-
gun.
Echocardiography. A real-time (color flow) Doppler
echocardiographic (Aloka 880) examination revealed a di-
lated but hyperdynamic left ventricle and excessive motion
of a portion of the posterior prosthetic aortic valve . Signif-
icantly, the left ventricular outflow tract at the anterior mitral
valve juncture was disrupted, with two linear, highly mobile
strands prolapsing into the left atrium providing a direct
communication between the left ventricular outflow tract
and the left atrium (Fig . 1). An abnormal flow pattern was
documented by color flow Doppler echocardiography, with
direct shunting from the left ventricular outflow tract into
the left atrium (Fig . 2), most consistent with a ruptured
abscess . There was also moderate paravalvular aortic re-
gurgitation and mild mitral regurgitation.
0735-1097/87/$3 .50
JACC Vol. 10. No. I
July 1987:222-4
FISHER ET AL.
VENTRICULOATRIAL COMMUNICATION IN PARAAORTIC ABSCESS
223
Figure I. Two-dimensional echocardiography. A, Parasternal long-
axis view. The arrow points to the ruptured abscess wall at the
junction of the anterior leaflet of the mitral valve andaortic root.
B, Short-axis view. Arrow points to the ruptured abscess at the
leftventricular (LV) outflow tract which isindirect communication
with the left atrium (LA). AO = aorta.
Surgery. The patient underwent open heart surgery for
mitral and aortic valve replacements and patch closure of
the communication. The patient's postoperative course was
complicated by sepsis and renal failure, and she died I
month after surgery.
Discussion
Infective endocarditis was first reported more than 300
years ago (5) and the complication of valve ring abscess
was described more than a century ago (6). Although the
frequency of prosthetic valve endocarditis is estimated to
be 1% (2,7), Arnett and Roberts (l) found all 22 patients
with prosthetic valve endocarditis to have valve ring abscess
at necropsy. Another study by Stinson (8) found 56% of
Figure2. Color flow Doppler study of thesame view as in Figure
2. Thewhitearrows ontheright side of theleftatrium demonstrate
turbulent flow (mosaic pattern) from the left ventricular outflow
tract (labeled AO foraortic outflow) andtheleftatrium (LA) . The
small black arrow on the left side of the left atrium marks the
area of mitral regurgitation.
patients with prosthetic valve endocarditis undergoing valve
replacement to have grossly obvious abscess formation.
Pathologic documentation of aortic root abscess. Valve
annular involvement in infective endocarditis occurs by di-
rect extension because the relatively avascular anulus offers
little resistance to infection (9). Burrowing of an aortic root
abscess into contiguous structures is probably abetted by
the high blood flow velocity and turbulence across the aortic
valve (2). Pathologic studies (2) of native aortic root abscess
havedocumentedextension from the aorta into the periaortic
space, through the atrial septum into the right and left atria
and through the ventricular septum into the right ventricle
and anterobasalleft ventricular wall (2). A recent pathologic
report (10) describes a cavity between the left ventricular
outflow tract just below the aortic valve extending to just
above the mitral anulus, with imminent rupture into the left
atrium. However, our present case demonstrated a com-
munication between the left ventricular outflow tract and
left atrium.
Diagnosis. The in vivo diagnosis of prosthetic aortic
valve ring abscess is difficult. Clinically, patients may pres-
ent with fever or congestive heart failure and be found to
have ECG prolongation of the PR interval. Echocardiog-
raphy may reveal excessive thickness of the aortic root (II) .
Though two-dimensional echocardiography can directly im-
age the typical echolucent cavity in the perivalvular tissue,
reports of only 10 native (3,4,10-14) and 5 prosthetic (15,17)
valve abscesses have been published. The present compli-
cation of infective endocarditis involved rupture of an aortic
224 FISHER ET AL.
VENTRICULOATRIAL COMMUNICATION IN PARAAORTIC ABSCESS
JACC Vol. 10, No. I
July 1987:222-4
prosthetic valve abscess, which created a direct communi-
cation between the left ventricle and left atrium. Addition-
ally, pulsed and color flow Doppler imaging documented
left ventricular to left atrial flow through the communication.
Rupture of the infravalvular abscess generated a significant
hemodynamic burden, precipitating congestive heart failure.
Also, the location of the abscess and its rupture may have
caused malfunction of the aortic prosthesis and mitral valve.
Differential diagnosis. Because of its proximity to the
mitral valve, a left ventricular outflow tract to left atrial
communication must be differentiated from valvular vege-
tation and ruptured sinus of Valsalva aneurysm. However,
mitral vegetations usually occur on the distal and midportion
of the leaflets themselves and rarely at the septal insertion
of the anterior leaflet. Furthermore, it is the right sinus of
Valsalva aneurysm that usually ruptures into the right atrium
or ventricle and not into the left atrium (18). In the present
case, the left ventricular outflow tract was involved, not the
aortic root. Rupture of the mitral-aortic intervalvular fibrosa
(interannular subaortic aneurysm) should also be considered
as a possible cause for the left ventricular outflow tract to
left atrial communication (8,19).
Surgical implications. Rapid and accurate detection of
an abscess complicating endocarditis may reduce the in-
creased morbidity and mortality associated with its presence
(14,20,21). Even when successfully diagnosed, an abscess
presents surgical problems. Sutures placed deeply into the
ventricular septum in an attempt to obliterate an erosive
aortic abscess can produce heart block (8,22). Also, sutures
in the aortic anulus and mitral-aortic intervalvular fibrosa
can cause valvular regurgitation (8).
Summary. We have described an additional complica-
tion of prosthetic valve endocarditis, the degeneration of an
abscess into a direct communication between the left ven-
tricular outflow tract and the left atrium. Real-time Doppler
flow mapping (color flow) proved useful in the definitive
diagnosis of this serious complication of infective endocar-
ditis. Physicians should be aware of this potential compli-
cation of aortic prosthetic endocarditis when a patient with
endocarditis suddenly develops heart failure. Two-dimen-
sional echocardiography can identify the abscess and its
rupture, whereas color flow or routine pulsed Doppler echo-
cardiography can confirm the abnormal flow pattern.
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Left ventricular to left atrial communication secondary to a paraaortic abscess: Color flow doppler documentation 

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Left ventricular to left atrial communication secondary to a paraaortic abscess: Color flow doppler documentation

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