Aortic root abscess and the lost art of the physical exam

Sir,

Severe aortic valve insufficiency (AI) is a condition that is considered a medical emergency when it presents in the acute setting. If the condition is not properly diagnosed and treated, it will quickly progress into cardiogenic shock. The two most common causes of acute AI of a native aortic valve are infective endocarditis (IE) and aortic dissection.[1]

A 69-year-old woman with past medical history of hypertension, diabetes mellitus, cerebrovascular accident with residual right hemiparesis, coronary artery disease, and peripheral vascular disease was admitted to the hospital, placed on bowel rest, and started on intravenous antibiotics after computed tomography (CT) scan of the abdomen and pelvis showed mild right-sided colitis.

On day 5, the patient presented with new-onset atrial fibrillation and first-degree atrioventricular (AV) block, which then progressed to a second-degree (Mobitz I) AV block later that day. The patient became febrile and had a concurrent leukocytosis with a repeat CT scan showing acute cholecystitis, after which an emergency laparoscopic cholecystectomy was scheduled. Prior to transport, a third-degree AV block was noticed in the telemetry monitor, so external pacemaker pads were applied and transvenous pacemaker placement was added to the surgery. While in the preoperative holding unit, the patient was evaluated by the anesthesiologist, whose focused cardiac physical examination revealed a diastolic murmur with a widened pulse pressure and signs indicative of aortic incompetence, none of which were previously documented.

After induction of general anesthesia and subsequent placement of a transvenous pacemaker, the anesthesiologist performed a transesophageal echocardiography (TEE), revealing an aortic valve vegetation, a small aortic root abscess as well as severe AI with a preserved ejection fraction of 65% [Figure 1]. The cholecystectomy was completed laparoscopically and the patient was admitted to the intensive care unit.

Figure 1.

Intraoperative transesophageal echocardiogram (TEE) (midesophageal long-axis view of the aortic valve) showing an aortic valve (AV) vegetation (arrow 1) and an aortic root abscess (arrow 2)

On postoperative day 12, the patient underwent an aortic valve replacement. Intraoperatively, aortic valve vegetations were found, as well as a 1.5 × 2 cm subannular abscess under the noncoronary cusp. Fifteen days after the aortic valve replacement, the patient was discharged to a rehabilitation facility.

This case describes a patient who presented with generalized malaise, mild right lower quadrant pain, nausea, and vomiting. The presence of sepsis with colitis and an infected gallbladder made it difficult to consider the diagnosis of IE in the absence of known risk factors. Being able to distinguish an unexpected acute aortic incompetence from sepsis with a thorough physical examination coupled with strong clinical knowledge is essential for diagnosing this challenging entity.

Cardiac manifestations are the most common complications in patients with IE, as they may present in up to half of the cases.[2] The incidence of a perivalvular abscess is 30–40%, with the aortic valve and its annulus being more susceptible than the mitral valve and annulus.[3] Acute AI in native aortic valves is usually a consequence of IE or aortic dissection.[1] Because of the acuteness of its presentation, the classic signs and symptoms of chronic AI are sometimes not present and thus, once again, a high degree of clinical suspicion along with a focused cardiac physical examination and the ability to perform an intraoperative TEE is essential for making a timely diagnosis.[4]

When the patient initially presented to the hospital's emergency department, no cardiac abnormalities were present on the physical examination or were revealed on the electrocardiogram to warrant further cardiac evaluation. It was not until hospital day 5 when the patient presented worsening abdominal pain, leukocytosis, fever, and new-onset atrial fibrillation with associated rapidly progressing AV block all within 24 hours, and that there was a suspicion of a cardiac etiology.

The physical examination by the anesthesiologist is the last stable setting to evaluate a patient prior to entering the operating room. Even though there was no mention of murmurs or new cardiac findings in the patient's chart, it is imperative that the anesthesiologist perform a focused yet thorough examination as new findings may present or may have been previously missed. This was the case as several other teams repeatedly evaluated the patient throughout her hospital stay prior to presenting to the operating room, yet no mention of the new-onset diastolic murmur was noted.

Finally, it is important to note how the intraoperative usage of the TEE subsequently revealed the diagnosis and cause for the patient's deterioration. This brings to light the importance of utilizing this tool as part of the anesthesiologists’ skill set. This, once again, highlights the central role of the anesthesiologist in the perioperative surgical home model of care.

This letter underscores the importance of physical examination of the anesthesiologist as it may reveal imperative information that may have been previously missed by other clinicians and highlights the importance of the utilization of the intraoperative TEE as part of the anesthesiologist's skill set.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.