Case Study

An 80-year-old woman with a bioprosthetic aortic valve was hospitalized for chest pain and heart failure. Fever was documented during the hospitalization and blood cultures grew Staphylococcus epidermidis. She underwent transthoracic echocardiography (TTE) which showed that the aortic prosthetic valve was functionally normal with no stenosis or regurgitation, but the prosthetic leaflets were not well seen. Transesophageal echocardiogra-phy (TEE) was subsequently performed, showing nodular thickening of the aortic prosthetic leaflets but no valvular or perivalvular regurgitation. There was no evidence of vegetation or abscess.

She was continued on antibiotic treatment for infective endocarditis (IE). Ten days later, she developed cardiac arrest and could not be successfully resuscitated. Autopsy showed severe coronary artery disease, and a vegetation of 1 cm in diameter on one of the prosthetic aortic leaflets.

Although TEE has a high sensitivity and specificity in the detection of vegetation, false-negative studies such as this case do occur. A negative TEE study reduces the likelihood, but does not exclude the diagnosis of, IE. When there is a high clinical suspicion for IE, repeat TEE should be performed to look for evolving echocardiographic findings.

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