Paravalvular Abscess Causing Severe Aortic Insufficiency with Aorto-Right Ventricular Fistula

Paravalvular Abscess Causing Severe Aortic Insufficiency with Aorto-Right Ventricular Fistula | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Paravalvular Abscess Causing Severe Aortic Insufficiency with Aorto-Right Ventricular Fistula Dilesha Dilangi Kumanayaka, Eyad Ahmed, Himaja Dutt Chigurupati, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4178653/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract This is a case report of a large paravalvular abscess of the aortic valve (AV) causing severe aortic insufficiency, complicated by aortic root to right ventricular fistula, in a young patient who admits to intravenous drug use (IVDU) and presented with skin abscesses and septic shock. Our case highlights the cruciality of early detection, diagnosis, and management of aorto-cavitary fistulas by echocardiography, due to high mobility and mortality associated. Aortic valve abscess aortic root fistula right ventricular fistula Aortic valve endocarditis Valvular heart disease Transesophageal echocardiography aortic valve insufficiency Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Introduction Despite advances in imaging and diagnosis, infective endocarditis, an infection of the endocardium or heart valves, is associated with high morbidity and mortality rates. IE is most often caused by gram-positive streptococci, staphylococci, and enterococci infection, accounting for 80–90% of all cases, with Staphylococcus aureus specifically responsible for around 30% of cases in the developed world. These organisms enter the bloodstream and adhere to damaged or abnormal endothelium, resulting in colonization and proliferation with monocyte recruitment, thrombosis, and inflammation ( 1 ). Echocardiography assesses the number, size, shape, location, echogenicity, and mobility of vegetations, so it is also useful for assessment of associated complications such as embolic risk, fistulas, periannular complications, mycotic aneurysms. Although complications of uncontrolled infection are relatively uncommon, they can cause rapid clinical deterioration and increased morbidity. Echocardiography is also useful for the diagnosis and management of the complications of IE, helping the physician in decision-making, particularly when a surgical intervention is indicated ( 2 ). The incidence of fistula formation complicating IE is unknown but it has been estimated to account for < 1% of all cases of IE in the antibiotic era. The incidence of perivalvular abscess stemming from IE is between 30–40%, with the aortic valve having a higher predisposition than the mitral valve and annulus ( 3 ). These fistulas can create intracardiac shunts causing rapid clinical deterioration and hemodynamic instability. Intravenous drug use is a known risk factor for IE and its associated risk is several-folds higher than that for patients with rheumatic heart disease or prosthetic valves ( 4 ). We present an extremely unique case of a large paravalvular abscess of the aortic valve (AV) causing severe aortic insufficiency, complicated by aortic root to right ventricular fistula, in a young patient who admits to intravenous drug use (IVDU) and presented with skin abscesses and septic shock. Case Presentation A patient in their 20s, with no known past medical history was brought into the emergency department by EMS, after the patient found unconscious by a friend. When evaluated in the emergency department (ED) after ED providers had transferred care to critical care team, patient stated that they remembered injecting drugs, before losing consciousness, but that they woke up in the ED after Naloxone was given. Patient was tachypneic, tachycardic, febrile and hypotensive (with wide pulse pressure) on presentation and was started on vasopressors (norepinephrine) after fluid resuscitation. Physical exam was remarkable for a decrescendo early-diastolic blowing murmur that was heard throughout the chest, bounding pulses and multiple necrotic skin lesions on all extremities with injection scars. Infective endocarditis was highly likely on differential diagnosis at this time, based on Duke’s criteria. On admission, patient was started on broad spectrum antibiotics; Vancomycin, which covers gram positive bacteria including methicillin resistant Staphylococcus aureus and Piperacillin and Tazobactam, which covers gram negative bacteria including Pseudomonas aeruginosa, gram positive as well as anaerobic bacteria. After two blood cultures came back positive for gram positive cocci in clusters, antibiotics were changed to high dose Daptomycin for definitive treatment of IE caused by Staphylococcus aureus. Transthoracic echocardiography (TTE) was performed on admission which showed severe aortic insufficiency (AI) with early closure of the mitral valve, interatrial septum bowed towards the right, with mildly reduced left ventricular ejection fraction, but with no vegetations. Transesophageal echocardiography (TEE) was recommended and was then performed. TEE showed extremely severe AI (Fig. 1–4) with pressure half time of 37msec, 1.6 x 0.8cm para-AV abscess that is adjacent to the right and non coronary cusps (Fig. 5), just distal to the tricuspid valve. A shunt was also noted from aortic root to right ventricle via colour doppler (Figs. 6 and 7). There was also 0.7cm vegetation on the right coronary cups and 1.1 cm vegetation on the non-coronary cusp of the AV. The vegetations on the non and right coronary cusps caused prolapse of the aortic valve (Fig. 8). Cardiothoracic surgery in the hospital was consulted, but due to the complexity of the case also requiring aortic root graft, patient had to be transferred to another hospital. Patient was then informed of these findings, while arrangements were being made to possibly transfer the patient. A few hours later, patient went in to cardiac arrest, requiring two cycles of cardiopulmonary resuscitation and Epinephrine twice. Patient was in pulseless electrical activity during this episode. ROSC was achieved, but mental status on Glasgow Coma Scale was < 8. Patient was still transferred to another hospital, where cardiothoracic surgery accepted the patient to perform surgery, but patient passed away a few hours after getting to that hospital. Discussion Our case involves a rare case of a large paravalvular abscess of the aortic valve (AV) causing severe aortic insufficiency, complicated by aortic root to right ventricular fistula, in a young patient who admits to IVDU and presented with skin abscesses and septic shock. IVDU is a widely recognized predisposing factor of IE, with an annual incidence of 1–5% in this population ( 4 ). It has been suggested that endothelial injury from injected particulate matter, direct injection of contaminated material, and drug-associated vasospasm leading to intimal damage and thrombus formation can lead to endocarditis with IVDU ( 5 ). Acquired aortic root to right ventricular communications are rare but can occur as fistulisation from IE, as in our case. Fistula formation is more common in prosthetic valve IE compared with native valve IE ( 4 ). Direct extension of infection from aortic valvular structures to surrounding perivalvular tissue may have resulted in intracardiac abscess formation and then may have caused a communication with the lumen of the aortic root and the right ventricle. The sensitivity of transthoracic echocardiography (TTE) for the detection of vegetations in patients with native valve endocarditis (NVE) is approximately 65%, whereas that of transesophageal echocardiography (TEE) in these patients is 85 to 95% ( 6 ). Our case highlights the cruciality of early detection, diagnosis, and management of aorto-cavitary fistulas due to high mobility and mortality. TTE and TEE play an extremely important role in fistula tract characterization in addition to detecting them, which is paramount importance in the pre-operative and intra-operative surgical planning and procedure selection. Declarations No datasets were generated or analysed during this case report. This is a case report that does not include patient identification information and has been approved by the REB (research Ethics Board) at Saint Michael’s Medical Center. Informed consent was obtained from the patient before she passed away a few days later and patient had no identified immediate family or friends present. The current case report was written in accordance with the CARE case report guidelines (refer to attached file under related files). None of the authors have conflicts of interest. There are no Competing Interests. There was no funding associated. Author Contribution Dilesha Kumanayaka wrote up the complete case and was the cardiology fellow that conducted all non-invasive testing and patient management with other cardiology fellow Eyad Ahmed, with the attending cardiologist Ahsan Khan who also read non-inasive and invasive imaging. Critical care team (Himaja Dutt, Priscilla Chow and Hari Sharma) was involved in patient management and procedure assistance. Acknowledgement No datasets were generated or analysed during this case report. References Barnett R. (2016). Infective endocarditis. Lancet (London, England), 388(10050), 1148. Sordelli, C., Fele, N., Mocerino, R., Weisz, S. H., Ascione, L., Caso, P., Carrozza, A., Tascini, C., De Vivo, S., & Severino, S. (2019). Infective Endocarditis: Echocardiographic Imaging and New Imaging Modalities. Journal of cardiovascular echography, 29(4), 149–155. Tuarez, F. J, R,, Yelamanchili, V. S., Law, M.A. (Updated 2023 Jul 17). Cardiac Abscess. [In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan. Anguera, I., Miro, J. M., Vilacosta, I., Almirante, B., Anguita, M., Muñoz, P., San Roman, J. A., de Alarcon, A., Ripoll, T., Navas, E., Gonzalez-Juanatey, C., Cabell, C. H., Sarria, C., Garcia-Bolao, I., Fariñas, M. C., Leta, R., Rufi, G., Miralles, F., Pare, C., Evangelista, A., … Aorto-cavitary Fistula in Endocarditis Working Group (2005). Aorto-cavitary fistulous tract formation in infective endocarditis: clinical and echocardiographic features of 76 cases and risk factors for mortality. European heart journal, 26(3), 288–297. Scheggi, V., Del Pace, S., Ceschia, N. et al. Infective endocarditis in intravenous drug abusers: clinical challenges emerging from a single-centre experience. BMC Infect Dis 21, 1010 (2021). Ghosh, S., Sahoo, R., Nath, R. K., Duggal, N., & Gadpayle, A. K. (2014). A Study of Clinical, Microbiological, and Echocardiographic Profile of Patients of Infective Endocarditis. International scholarly research notices, 2014, 340601. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4178653","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":299536213,"identity":"0cb15966-bb29-491a-b900-441050eed1bd","order_by":0,"name":"Dilesha Dilangi Kumanayaka","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAw0lEQVRIiWNgGAWjYDCCM1CaH0Ixk6BFsoFkLQYHiNXCd+aM6YafO+wSN58/fk2CocI6sYGQFsmzPWY3e88kJ267kVMmwXAmnbAWg/M8Zjd425iBWnjSJBjbDhOn5ebftvrEzf1ngFr+EaMF6LDbvEDDNzCkH5NgbCBCi+SZY2W3ZduOG8+4kcNskXAs3ZigFr4zydtuvm2rlu3vP/7wxocaa1mCWmDAsYGBx4AhgVjlIGDPwMD+gBQNo2AUjIJRMIIAAFiZRnxnxXswAAAAAElFTkSuQmCC","orcid":"","institution":"New York Medical College at Saint Michael's Medical Center","correspondingAuthor":true,"prefix":"","firstName":"Dilesha","middleName":"Dilangi","lastName":"Kumanayaka","suffix":""},{"id":299536214,"identity":"f33a5da1-8081-471b-bef4-06d11eeffcb4","order_by":1,"name":"Eyad Ahmed","email":"","orcid":"","institution":"New York Medical College at Saint Michael's Medical 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(TEE) Mid-esophageal Long-Axis View, showing severe aortic regurgitation by color doppler\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4178653/v1/95d7d4ab6ce761758e99286a.jpg"},{"id":56277038,"identity":"0cf2e576-7323-4514-94ed-4399cdd56074","added_by":"auto","created_at":"2024-05-10 20:13:13","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1786437,"visible":true,"origin":"","legend":"\u003cp\u003eTransesophageal echocardiography (TEE), Continuous wave doppler through the aortic valve (trans-gastric view) showing severe aortic regurgitation.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4178653/v1/bc5327e4859f11d461c350d0.jpg"},{"id":56276972,"identity":"db53516f-69cb-4d31-996a-41003d36b2e5","added_by":"auto","created_at":"2024-05-10 20:12:53","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1724765,"visible":true,"origin":"","legend":"\u003cp\u003eTransesophageal echocardiography (TEE), Pulse wave doppler of descending aorta demonstrating holo-diastolic flow reversal due to severe aortic regurgitation.\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4178653/v1/9344d85a2979510958eccb30.jpg"},{"id":56277037,"identity":"c88611a4-fdfd-4f5a-9c0a-252946f86e7b","added_by":"auto","created_at":"2024-05-10 20:13:13","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1400875,"visible":true,"origin":"","legend":"\u003cp\u003eTransesophageal echocardiography (TEE), Continuous wave doppler of descending aorta showing holo-diastolic flow reversal due to severe aortic regurgitation.\u003c/p\u003e","description":"","filename":"Figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4178653/v1/e990ab2a37fb3f5700a0a750.jpg"},{"id":56277035,"identity":"c02294d0-bdc2-4425-98e5-96000b8c85df","added_by":"auto","created_at":"2024-05-10 20:13:03","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":1269858,"visible":true,"origin":"","legend":"\u003cp\u003eTransesophageal echocardiography (TEE) Mid-esophageal, Aortic Valve Short-Axis View showing Paravalvular abscess with the red arrow\u003c/p\u003e","description":"","filename":"Figure5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4178653/v1/5e968e8a75bd681a83cb8ab4.jpg"},{"id":56276979,"identity":"2b84b47a-ac28-4098-86da-56275440bbe6","added_by":"auto","created_at":"2024-05-10 20:12:58","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":1112204,"visible":true,"origin":"","legend":"\u003cp\u003eTransesophageal echocardiography (TEE) Mid-esophageal Long axis view of Flow through paravalvular abscess into the right ventricle.\u003c/p\u003e","description":"","filename":"Figure6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4178653/v1/3964bc5374399ad83691f224.jpg"},{"id":56277023,"identity":"2b894676-68bc-457b-9e3e-05cb20c38462","added_by":"auto","created_at":"2024-05-10 20:13:02","extension":"jpg","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":1439045,"visible":true,"origin":"","legend":"\u003cp\u003eTransesophageal echocardiography (TEE) Mid-esophageal Short axis view of flow through aortic paravalvular abscess into the right ventricle\u003c/p\u003e","description":"","filename":"Figure7.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4178653/v1/d6c09df50da17a007dfcc794.jpg"},{"id":56277036,"identity":"863f7cf6-d308-460e-834c-9d664048c57a","added_by":"auto","created_at":"2024-05-10 20:13:10","extension":"jpg","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":1119147,"visible":true,"origin":"","legend":"\u003cp\u003eTransesophageal echocardiography (TEE) Mid-esophageal Long-Axis View, showing vegetations on the non and right coronary cusps causing prolapse of the aortic valve\u003c/p\u003e","description":"","filename":"Figure8.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4178653/v1/363f3a1174a43d858b94525a.jpg"},{"id":69892966,"identity":"b1ba0aff-594c-4846-984b-b33b31cdc478","added_by":"auto","created_at":"2024-11-26 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IE is most often caused by gram-positive streptococci, staphylococci, and enterococci infection, accounting for 80\u0026ndash;90% of all cases, with Staphylococcus aureus specifically responsible for around 30% of cases in the developed world. These organisms enter the bloodstream and adhere to damaged or abnormal endothelium, resulting in colonization and proliferation with monocyte recruitment, thrombosis, and inflammation (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Echocardiography assesses the number, size, shape, location, echogenicity, and mobility of vegetations, so it is also useful for assessment of associated complications such as embolic risk, fistulas, periannular complications, mycotic aneurysms. Although complications of uncontrolled infection are relatively uncommon, they can cause rapid clinical deterioration and increased morbidity. Echocardiography is also useful for the diagnosis and management of the complications of IE, helping the physician in decision-making, particularly when a surgical intervention is indicated (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The incidence of fistula formation complicating IE is unknown but it has been estimated to account for \u0026lt;\u0026thinsp;1% of all cases of IE in the antibiotic era. The incidence of perivalvular abscess stemming from IE is between 30\u0026ndash;40%, with the aortic valve having a higher predisposition than the mitral valve and annulus (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). These fistulas can create intracardiac shunts causing rapid clinical deterioration and hemodynamic instability. Intravenous drug use is a known risk factor for IE and its associated risk is several-folds higher than that for patients with rheumatic heart disease or prosthetic valves (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). We present an extremely unique case of a large paravalvular abscess of the aortic valve (AV) causing severe aortic insufficiency, complicated by aortic root to right ventricular fistula, in a young patient who admits to intravenous drug use (IVDU) and presented with skin abscesses and septic shock.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA patient in their 20s, with no known past medical history was brought into the emergency department by EMS, after the patient found unconscious by a friend. When evaluated in the emergency department (ED) after ED providers had transferred care to critical care team, patient stated that they remembered injecting drugs, before losing consciousness, but that they woke up in the ED after Naloxone was given. Patient was tachypneic, tachycardic, febrile and hypotensive (with wide pulse pressure) on presentation and was started on vasopressors (norepinephrine) after fluid resuscitation. Physical exam was remarkable for a decrescendo early-diastolic blowing murmur that was heard throughout the chest, bounding pulses and multiple necrotic skin lesions on all extremities with injection scars. Infective endocarditis was highly likely on differential diagnosis at this time, based on Duke\u0026rsquo;s criteria. On admission, patient was started on broad spectrum antibiotics; Vancomycin, which covers gram positive bacteria including methicillin resistant Staphylococcus aureus and Piperacillin and Tazobactam, which covers gram negative bacteria including Pseudomonas aeruginosa, gram positive as well as anaerobic bacteria. After two blood cultures came back positive for gram positive cocci in clusters, antibiotics were changed to high dose Daptomycin for definitive treatment of IE caused by Staphylococcus aureus. Transthoracic echocardiography (TTE) was performed on admission which showed severe aortic insufficiency (AI) with early closure of the mitral valve, interatrial septum bowed towards the right, with mildly reduced left ventricular ejection fraction, but with no vegetations. Transesophageal echocardiography (TEE) was recommended and was then performed. TEE showed extremely severe AI (Fig.\u0026nbsp;1\u0026ndash;4) with pressure half time of 37msec, 1.6 x 0.8cm para-AV abscess that is adjacent to the right and non coronary cusps (Fig.\u0026nbsp;5), just distal to the tricuspid valve. A shunt was also noted from aortic root to right ventricle via colour doppler (Figs.\u0026nbsp;6 and 7). There was also 0.7cm vegetation on the right coronary cups and 1.1 cm vegetation on the non-coronary cusp of the AV. The vegetations on the non and right coronary cusps caused prolapse of the aortic valve (Fig.\u0026nbsp;8). Cardiothoracic surgery in the hospital was consulted, but due to the complexity of the case also requiring aortic root graft, patient had to be transferred to another hospital. Patient was then informed of these findings, while arrangements were being made to possibly transfer the patient. A few hours later, patient went in to cardiac arrest, requiring two cycles of cardiopulmonary resuscitation and Epinephrine twice. Patient was in pulseless electrical activity during this episode. ROSC was achieved, but mental status on Glasgow Coma Scale was \u0026lt;\u0026thinsp;8. Patient was still transferred to another hospital, where cardiothoracic surgery accepted the patient to perform surgery, but patient passed away a few hours after getting to that hospital.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur case involves a rare case of a large paravalvular abscess of the aortic valve (AV) causing severe aortic insufficiency, complicated by aortic root to right ventricular fistula, in a young patient who admits to IVDU and presented with skin abscesses and septic shock. IVDU is a widely recognized predisposing factor of IE, with an annual incidence of 1\u0026ndash;5% in this population (\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e). It has been suggested that endothelial injury from injected particulate matter, direct injection of contaminated material, and drug-associated vasospasm leading to intimal damage and thrombus formation can lead to endocarditis with IVDU (\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e). Acquired aortic root to right ventricular communications are rare but can occur as fistulisation from IE, as in our case. Fistula formation is more common in prosthetic valve IE compared with native valve IE (\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e). Direct extension of infection from aortic valvular structures to surrounding perivalvular tissue may have resulted in intracardiac abscess formation and then may have caused a communication with the lumen of the aortic root and the right ventricle. The sensitivity of transthoracic echocardiography (TTE) for the detection of vegetations in patients with native valve endocarditis (NVE) is approximately 65%, whereas that of transesophageal echocardiography (TEE) in these patients is 85 to 95% (\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e). Our case highlights the cruciality of early detection, diagnosis, and management of aorto-cavitary fistulas due to high mobility and mortality. TTE and TEE play an extremely important role in fistula tract characterization in addition to detecting them, which is paramount importance in the pre-operative and intra-operative surgical planning and procedure selection.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eNo datasets were generated or analysed during this case report. This is a case report that does not include patient identification information and has been approved by the REB (research Ethics Board) at Saint Michael\u0026rsquo;s Medical Center. Informed consent was obtained from the patient before she passed away a few days later and patient had no identified immediate family or friends present. The current case report was written in accordance with the CARE case report guidelines (refer to attached file under related files). None of the authors have conflicts of interest. There are no Competing Interests. There was no funding associated.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eDilesha Kumanayaka wrote up the complete case and was the cardiology fellow that conducted all non-invasive testing and patient management with other cardiology fellow Eyad Ahmed, with the attending cardiologist Ahsan Khan who also read non-inasive and invasive imaging. Critical care team (Himaja Dutt, Priscilla Chow and Hari Sharma) was involved in patient management and procedure assistance.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eNo datasets were generated or analysed during this case report.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eBarnett R. (2016). Infective endocarditis. Lancet (London, England), 388(10050), 1148.\u003c/li\u003e\n \u003cli\u003eSordelli, C., Fele, N., Mocerino, R., Weisz, S. H., Ascione, L., Caso, P., Carrozza, A., Tascini, C., De Vivo, S., \u0026amp; Severino, S. (2019). Infective Endocarditis: Echocardiographic Imaging and New Imaging Modalities. Journal of cardiovascular echography, 29(4), 149\u0026ndash;155.\u003c/li\u003e\n \u003cli\u003eTuarez, F. J, R,, Yelamanchili, V. S., Law, M.A. (Updated 2023 Jul 17). Cardiac Abscess. [In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan.\u003c/li\u003e\n \u003cli\u003eAnguera, I., Miro, J. M., Vilacosta, I., Almirante, B., Anguita, M., Mu\u0026ntilde;oz, P., San Roman, J. A., de Alarcon, A., Ripoll, T., Navas, E., Gonzalez-Juanatey, C., Cabell, C. H., Sarria, C., Garcia-Bolao, I., Fari\u0026ntilde;as, M. C., Leta, R., Rufi, G., Miralles, F., Pare, C., Evangelista, A., \u0026hellip; Aorto-cavitary Fistula in Endocarditis Working Group (2005). Aorto-cavitary fistulous tract formation in infective endocarditis: clinical and echocardiographic features of 76 cases and risk factors for mortality. European heart journal, 26(3), 288\u0026ndash;297.\u003c/li\u003e\n \u003cli\u003eScheggi, V., Del Pace, S., Ceschia, N. et al. Infective endocarditis in intravenous drug abusers: clinical challenges emerging from a single-centre experience. BMC Infect Dis 21, 1010 (2021).\u003c/li\u003e\n \u003cli\u003eGhosh, S., Sahoo, R., Nath, R. K., Duggal, N., \u0026amp; Gadpayle, A. K. (2014). A Study of Clinical, Microbiological, and Echocardiographic Profile of Patients of Infective Endocarditis. International scholarly research notices, 2014, 340601.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Aortic valve abscess, aortic root fistula, right ventricular fistula, Aortic valve endocarditis, Valvular heart disease, Transesophageal echocardiography, aortic valve insufficiency","lastPublishedDoi":"10.21203/rs.3.rs-4178653/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4178653/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThis is a case report of a large paravalvular abscess of the aortic valve (AV) causing severe aortic insufficiency, complicated by aortic root to right ventricular fistula, in a young patient who admits to intravenous drug use (IVDU) and presented with skin abscesses and septic shock. Our case highlights the cruciality of early detection, diagnosis, and management of aorto-cavitary fistulas by echocardiography, due to high mobility and mortality associated.\u003c/p\u003e","manuscriptTitle":"Paravalvular Abscess Causing Severe Aortic Insufficiency with Aorto-Right Ventricular Fistula","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-10 20:11:34","doi":"10.21203/rs.3.rs-4178653/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0da253c9-d47f-42a5-8f59-597890a6b39b","owner":[],"postedDate":"May 10th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-11-26T10:38:49+00:00","versionOfRecord":[],"versionCreatedAt":"2024-05-10 20:11:34","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4178653","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4178653","identity":"rs-4178653","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}