LAUSR

A 74-year-old man was admitted with severe posterior neck pain and fever for 14 days. He had undergone mitral valve replacement (MVR) using a Carpentier-Edwards PERIMOUNT bioprosthetic valve (Edwards Lifesciences, Irvine, CA) for mitral regurgitation (MR) 14 years earlier. Contrastenhanced computed tomography revealed an abscess at the right spinal neck. Transthoracic echocardiography (TTE) revealed mild MR and a flail motion of the posteromedial cusp of the bioprosthetic valve without obvious vegetation (Fig. 1a). Blood cultures detected Streptococcus parasanguinis; therefore, he was suspected to have prosthetic valve endocarditis (PVE). Three days after the initiation of intravenous antibiotics, he had acute congestive heart failure with cardiogenic shock. TTE showed a significant flail motion of the posteromedial cusp of the bioprosthetic valve (Fig. 1b). Transesophageal echocardiography (TEE) revealed detachment of the prosthetic valve (Fig. 1c white asterisk, video 1), severe MR throughout the detachment (Fig. 1c white arrow, video 1), and a mobile vegetation located on the posterior region (Fig. 1c white arrowhead, video 1). Threedimensional TEE image showed marked detachment of the prosthetic valve, which extended up to half of the valve annulus (Fig. 1d white asterisk, video 2) causing severe MR (Fig. 1e white arrow, video 3). We performed emergency MVR, and the patient was discharged without any complication after 8 week antibiotic therapy. We experienced a case of PVE complicated with cardiogenic shock and severe MR with prosthetic valve detachment, which progressed rapidly despite antibiotics therapy. Mechanical complications must be considered in the event of hemodynamic deterioration in patients with infective endocarditis [1].