A 65-year-old man presented with fever and a general feeling of being unwell. He had a bioprosthetic aortic valve — a detail that immediately gave the fever a different significance.
The ECG added the finding that sharpened our concern: complete atrioventricular block. In a febrile patient with an aortic valve prosthesis, that combination raises a specific question: could infection have extended into the tissue surrounding the valve?
We performed transthoracic echocardiography, followed by transesophageal echocardiography. The studies revealed prosthetic aortic valve endocarditis, with vegetations and a periannular abscess involving the tissue around the prosthetic sewing ring.
The rhythm disturbance and the imaging findings now formed a coherent clinical picture.
The aortic annulus lies close to the membranous septum and the penetrating atrioventricular conduction bundle. Infection extending into this region can disrupt conduction between the atria and ventricles. In this setting, complete AV block is a warning sign of possible perivalvular extension; echocardiography establishes the structural complication.
The location of the abscess matters. A ring abscess involves infected tissue around the prosthetic sewing cuff. It represents extension beyond the valve leaflets, with implications for the integrity of the surrounding structures. In this case, that periannular involvement provided a plausible anatomical explanation for the conduction abnormality.
Transesophageal imaging was particularly valuable. Prosthetic material can obscure important findings on transthoracic views, and the assessment needs to include the sewing ring and adjacent aortic root as well as the valve itself. Seeing vegetations is only part of understanding the extent of the infection.
This combination also changes the urgency of the assessment. Complete AV block requires immediate attention to rhythm and haemodynamic stability, while prosthetic valve infection with an abscess calls for urgent multidisciplinary evaluation, including cardiac surgery.
What stayed with me was the sequence: fever raised suspicion, the ECG directed attention to extension around the valve, and echocardiography revealed the anatomy behind that concern.
Sometimes, an electrical finding tells us where to look for a structural complication.
