Valvulitis: a new echocardiographic criterion for the diagnosis of bioprosthetic aortic valve infective endocarditis

INTRODUCTION AND OBJECTIVES

Diffuse homogeneous hypoechoic leaflet thickening, with a wavy leaflet motion documented by transesophageal echocardiography (TEE), has been described in some cases of prosthetic valve endocarditis (PVE) involving aortic bioprosthesis (AoBio-PVE). This echocardiographic finding has been termed valvulitis. We aimed to estimate the prevalence of valvulitis, precisely describe its echocardiographic characteristics, and determine their clinical significance in patients with AoBio-PVE.

METHODS

From 2011 to 2022, 388 consecutive patients with infective endocarditis (IE) admitted to a tertiary care hospital were prospectively included in a multipurpose database. For this study, all patients with AoBio-PVE (n=86) were selected, and their TEE images were thoroughly evaluated by 3 independent cardiologists to identify all cases of valvulitis.

RESULTS

The prevalence of isolated valvulitis was 12.8%, and 20.9% of patients had valvulitis accompanied by other classic echocardiographic findings of IE. A total of 9 out of 11 patients with isolated valvulitis had significant valve stenosis, whereas significant aortic valve regurgitation was documented in only 1 patient. Compared with the other patients with AoBio-PVE, cardiac surgery was less frequently performed in patients with isolated valvulitis (27.3% vs 62.7%, P=.017). In 4 out of 5 patients with valve stenosis who did not undergo surgery but underwent follow-up TEE, valve gradients significantly improved with appropriate antibiotic therapy.

CONCLUSIONS

Valvulitis can be the only echocardiographic finding in infected AoBio and needs to be identified by imaging specialists for early diagnosis. However, this entity is a diagnostic challenge and additional imaging techniques might be required to confirm the diagnosis. Larger series are needed.

Multiple Strokes Secondary to an Early Thrombosis of Aortic Bioprosthesis on Aspirin Therapy

We describe here a rare case of a 74-year-old man with essential thrombocythemia who presented an early nonobstructive thrombosis of aortic porcine bioprosthesis complicated by multiple ischemic strokes 14 days after the primary operation. Transesophageal echocardiography on the postoperative day (POD) 17 revealed a mobile, nonobstructive thrombosis inserted on the anterior cusp right of the bioprosthesis. Anticoagulation by intravenous unfractionated heparin was effective with disappearance of the thrombus with good aortic prosthesis function on the POD 20 without requiring reoperation. The patient had a complete recovery of neurological disorders and was discharged on POD 26.