We present the case of an 81-year-old man with severe aortic stenosis, heart failure, and extensive comorbidities, who was accepted during a clinical session for transcatheter aortic valve transplantation. The procedure was feasible given his cardiac anatomy (Figure 1A).
Four weeks later, while on the waiting list, he presented with acute pulmonary edema and methicillin-resistant Staphylococcus epidermidis blood infection, attributed to a central catheter. He was treated with antibiotics and it was confirmed that his blood cultures had become negative; transthoracic echocardiography was normal. One month later, aortography prior to implantation showed a surprising mobile image in the heart chamber, dependent on the valve leaflet (Figure 1B and Video 1 of the supplementary material) and consequently the procedure was suspended. Transesophageal echocardiography confirmed aortic vegetation along with severe regurgitation (Figure 2A and B), and therefore antibiotic treatment was maintained for a further month. After this period, with negative blood cultures, positron emission tomography ruled out aortic capture (Figure 2C). In view of the above, and because the surgical risk was deemed to be very high and the infection to be eradicated, the indication for transcatheter valve implantation was maintained. This was performed with a 29-mm CoreValve aortic prosthesis (Figure 2D and Video 2 of the supplementary material). The patient progressed favorably without any incidents after 6 months.
Protocol-mandated aortography enabled the vegetation to be identified and the procedure to be suspended. The use of positron emission tomography, or labeled leukocyte scintigraphy, is key in these cases to rule out an infectious process. Finally, the case highlights the possibility of complications in patients with severe aortic stenosis on the waiting list for a procedure.