Recommended Citation
Hyder SM, Paolella G, Bentsen C, Kashlan B, Hussain SM. Silent Progression to Sudden Collapse: Prosthetic Valve Failure with Root Pseudoaneurysm. Presented at Scientific Day; May 20, 2026; Milwaukee, WI.
Abstract
Introduction/Background:
Structural complications following prosthetic valve endocarditis (PVE) may progress subtly over time, with early imaging abnormalities often underestimated. Delayed recognition can result in abrupt hemodynamic collapse. This case highlights the importance of maintaining suspicion for evolving prosthetic valve pathology despite initially reassuring studies.
Description:
A 57-year-old male with prior surgical bioprosthetic aortic valve and ascending aortic root replacement developed progressive dyspnea resulting in acute hypoxic respiratory failure and cardiogenic shock (CS). Three months earlier, a transthoracic echocardiogram (TTE) demonstrated mild aortic insufficiency (AI), leaflet thickening, and a small hypodensity, deemed nonspecific given negative transesophageal echocardiogram (TEE). Repeat TTE during clinical decompensation revealed severe AI, aneurysmal dilation of the sinus of Valsalva with rupture, and possible prosthetic dehiscence, representing a dramatic interval change. Subsequent TEE confirmed excessive prosthetic motion, global thickening of the bioprosthesis, a mobile echodensity attached to the bioprosthetic aortic valve, and an aortic root pseudoaneurysm. Computed tomography angiography demonstrated multiple aortic root outpouchings with marked root dilation. Hemodynamic assessment showed markedly elevated right- and left-sided filling pressures with reduced cardiac index, confirming valvular failure as the primary driver of CS. Despite persistently negative blood cultures, the index of suspicion remained high for culture-negative PVE due to rapid structural deterioration. Surgical intervention was initially contraindicated due to multifocal embolic cerebral infarcts with intracranial hemorrhage. The patient was medically stabilized with inotropic support, afterload reduction, and aggressive diuresis. Following neurologic stabilization, he underwent complex redo aortic root replacement with concomitant cardiac repair. Postoperative course required VA-ECMO support prior to final recovery.
Discussion:
This case illustrates how subtle echocardiographic abnormalities may represent early manifestations of progressive prosthetic valve failure, even in the absence of definitive infection or positive cultures. In patients with prosthetic valves and new or worsening symptoms, index of suspicion for prosthetic complications should be high. Evaluation should include careful reassessment of prior imaging findings, early repeat multimodality imaging, and close surveillance.
Presentation Notes
Presented at Scientific Day; May 20, 2026; Milwaukee, WI.
Full Text of Presentation
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Document Type
Poster
Open Access
Available to all.
Silent Progression to Sudden Collapse: Prosthetic Valve Failure with Root Pseudoaneurysm
Introduction/Background:
Structural complications following prosthetic valve endocarditis (PVE) may progress subtly over time, with early imaging abnormalities often underestimated. Delayed recognition can result in abrupt hemodynamic collapse. This case highlights the importance of maintaining suspicion for evolving prosthetic valve pathology despite initially reassuring studies.
Description:
A 57-year-old male with prior surgical bioprosthetic aortic valve and ascending aortic root replacement developed progressive dyspnea resulting in acute hypoxic respiratory failure and cardiogenic shock (CS). Three months earlier, a transthoracic echocardiogram (TTE) demonstrated mild aortic insufficiency (AI), leaflet thickening, and a small hypodensity, deemed nonspecific given negative transesophageal echocardiogram (TEE). Repeat TTE during clinical decompensation revealed severe AI, aneurysmal dilation of the sinus of Valsalva with rupture, and possible prosthetic dehiscence, representing a dramatic interval change. Subsequent TEE confirmed excessive prosthetic motion, global thickening of the bioprosthesis, a mobile echodensity attached to the bioprosthetic aortic valve, and an aortic root pseudoaneurysm. Computed tomography angiography demonstrated multiple aortic root outpouchings with marked root dilation. Hemodynamic assessment showed markedly elevated right- and left-sided filling pressures with reduced cardiac index, confirming valvular failure as the primary driver of CS. Despite persistently negative blood cultures, the index of suspicion remained high for culture-negative PVE due to rapid structural deterioration. Surgical intervention was initially contraindicated due to multifocal embolic cerebral infarcts with intracranial hemorrhage. The patient was medically stabilized with inotropic support, afterload reduction, and aggressive diuresis. Following neurologic stabilization, he underwent complex redo aortic root replacement with concomitant cardiac repair. Postoperative course required VA-ECMO support prior to final recovery.
Discussion:
This case illustrates how subtle echocardiographic abnormalities may represent early manifestations of progressive prosthetic valve failure, even in the absence of definitive infection or positive cultures. In patients with prosthetic valves and new or worsening symptoms, index of suspicion for prosthetic complications should be high. Evaluation should include careful reassessment of prior imaging findings, early repeat multimodality imaging, and close surveillance.
Affiliations
Advocate Lutheran General Hospital