In this article, we report a case of transcatheter aortic valve implantation (TAVI) endocarditis complicated by aortic root pseudoaneurysm. An 81-year-old female patient with a history of severe aortic stenosis underwent TAVI one year prior. She presented to our hospital with symptoms of fatigue, fever, and weight loss. Blood cultures confirmed infective endocarditis, and although transesophageal echocardiography revealed an abscess at the aortic root, electrocardiography-gated computed tomography (CT) angiography demonstrated the presence of an aortic root pseudoaneurysm ( Figure 1).

Figure 1: Preoperative ECG-gated CT angiography revealing a pseudoaneurysm at the aortic root (blue arrow). ECG: Electrocardiogram? CT: Computed tomography.

Written informed consent was obtained from the patient. Under general anesthesia, a median sternotomy was performed. The patient was heparinized. Arterial cannulation was achieved through an end-to-side anastomosis of an 8-mm Dacron® graft to the innominate artery. Bicaval venous cannulation was achieved. A vent was placed in the right upper pulmonary vein. A retrograde cardioplegia cannula was inserted into the coronary sinus, and cardiopulmonary bypass (CPB) was initiated. Cardiac arrest was achieved with systemic hypothermia at 24°C, retrograde cardioplegia, and cross-clamp. An aortotomy was performed, and the infected TAVI graft was removed ( Figure 2). The native aortic cusps were excised. A pseudoaneurysm ostium opening into the aortic root was identified adjacent to the left coronary ostium ( Figure 3). The defect was repaired with a pericardial patch ( Figure 4). The sutures for the aortic valve were then placed in the annulus. During the implantation of the 19-mm mechanical aortic valve, aortic tissue to be ruptured under the pericardial patch due to fragility of the annular tissue. As there was no annular tissue in the left annular region suitable for the implantation of a tube graft, the left ventricular outflow tract (LVOT) was reconstructed using a Dacron® graft. Initially, an 8-mm Dacron® tube graft was anastomosed end-to-end with the left main coronary artery (LMCA), followed by the implantation of the 21/24 mm valved conduit ( Figure 5). Subsequently, an 8-mm Dacron® tube graft was anastomosed to the right coronary artery (RCA) ostium, and a root cannula was inserted into the graft. Finally, the 8-mm tube graft between the LMCA and RCA was anastomosed side-to-side to the valved conduit graft. During the weaning from CPB (CPB time: 262 min, cross-clamp time: 202 min), no bleeding was observed from the aortic root. The patient was transferred to the intensive care unit. Despite being normotensive under adrenaline, dopamine, and noradrenaline support, the patient required high-dose vasoconstrictors in the seventh postoperative hour. Postoperative echocardiography revealed normal functioning of the prosthetic aortic valve. Also, there was no postoperative bleeding. Acute kidney injury (AKI) occurred, followed by refractory metabolic acidosis, which subsequently progressed to circulatory failure, eventually resulting in death.

Figure 2: Intraoperative image showing the removal of the infected transcatheter aortic valve implantation graft.

Figure 3: Pseudoaneurysm ostium adjacent to the left coronary ostium, visible after excision of the native aortic leaflets (white arrow).

Figure 4: Pericardial patch repair of the pseudoaneurysm ostium located in the aortic root (white arrow).

Figure 5: Surgical reconstruction, including the implantation of the 21/24 mm valved conduit (blue arrow) and the anastomosed 8-mm Dacron® tube graft to the LMCA (green arrow) and LVOT was reconstructed using a Dacron® graft (black arrow). LMCA: Left main coronary artery? LVOT: Left ventricular outflow tract.

Infective endocarditis after TAVI is a growing concern, with its incidence being reported between 0.5 and 1.4% in the literature.[1] It is typically associated with worse outcomes than surgical aortic valve replacement (SAVR), largely due to the comorbidities of the patient population.[2] In our case, an 81-year-old female patient developed TAVI valve endocarditis, which was further complicated by the presence of an aortic root pseudoaneurysm.

Pseudoaneurysm formation after TAVI, although rare, has been documented in a few reports. Vejtasova et al.[3] reported a case of pseudoaneurysm formation due to TAVI-related endocarditis.

The management of TAVI-related endocarditis often involves a combination of aggressive antibiotic therapy and surgical intervention. The need for prompt surgical debridement and replacement of the infected valve is essential. Such extensive reconstruction has been previously advocated as a means to address the complex anatomical challenges presented by cases of destructive endocarditis.[4] Rather than simply closing an isolated aortic pseudoaneurysm with a patch, the pressure and damage exerted on the annulus and subannular tissue during and after TAVI implantation, along with the destruction caused by endocarditis, weaken the annular tissue during TAVI remove. Reinforcing the annulus with a patch helps reduce postoperative bleeding, tears, pseudoaneurysm formation, mortality, and morbidity. Bioprosthetic solutions, such as the use of homografts or stentless valves, should be prioritized. In this case, surgical management was crucial and involved valve remove, LVOT reconstruction with a Dacron® graft, and aortic root replacement using the Cabrol procedure. In addition to the surgical approach, the decision to reconstruct the LVOT using a Dacron® graft was necessitated by the fragility of the native tissue and the size of the pseudoaneurysm. Similar cases have reported the use of Dacron® grafts and bioprosthetic valves to ensure structural integrity and reduce mechanical stress on the annular suture lines.[4] This technique was effective in managing the aortic root pseudoaneurysm.

Despite surgical efforts, the patient"s postoperative course was complicated by AKI and refractory metabolic acidosis, leading to circulatory failure.

In conclusion, this case illustrates the complexity of managing rare complications such as infective endocarditis and aortic root pseudoaneurysm following transcatheter aortic valve implantation. While transcatheter aortic valve implantation has become an essential therapeutic option for high-risk patients, it is of utmost importance to recognize that complications such as these, though rare, can result in severe outcomes. In cases where annular destruction and other structural complications are present, complex surgical interventions, such as valve remove and left ventricular outflow tract reconstruction, may offer the most optimal chance for a favorable outcome. However, even with timely and aggressive surgical management, the postoperative course remains challenging, particularly in elderly and high-risk patients. This underscores the need for ongoing vigilance, comprehensive perioperative management, and the development of more effective strategies to mitigate the risk of such complications.

Data Sharing Statement: The data that support the findings of this study are available from the corresponding author upon reasonable request.

Author Contributions: Concept and design, analysis and interpretation: B.B., İ.Y.A., M.K.K., Supervision and critical review: T.D., M.K., Data collection and processing, manuscript writing: B.B., İ.Y.A., Literature review: M.K.K., İ.Y.A., Funding and references: B.B., Materials provision: M.K. All authors have read and approved the final version of the manuscript and agree to be accountable for all aspects of the work.

Conflict of Interest: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Funding: The authors received no financial support for the research and/or authorship of this article.

References

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2) Amat-Santos IJ, Messika-Zeitoun D, Eltchaninoff H, Kapadia S, Lerakis S, Cheema AN, et al. Infective endocarditis after transcatheter aortic valve implantation: Results from a large multicenter registry. Circulation 2015;131:1566-74. doi: 10.1161/CIRCULATIONAHA.114.014089.

3) Vejtasova V, Bonaventura J, Topalo R, Veselka J. Ascending aorta pseudoaneurysm as a rare, late complication after valve-in-valve transcatheter aortic valve implantation procedure. Acta Cardiol Sin 2022;38:642-5. doi: 10.6515/ ACS.202209_38(5).20220330C.

4) Smail H, Saxena P, Zimmet AD, McGiffin DC. Reconstruction and replacement of the aortic root in destructive endocarditis. Oper Tech Thorac Cardiovasc Surg 2016;21:1-10.