A Root With Two Exits: Bioprosthetic Aortic Root Abscess With Dual Aorto-Arial Fistulae

Authors

• Mohamed Hani Abdalaziz, Corewell Health East Resident
• Danny A. Mohama, Corewell Health East Fellow
• Aiden M. Van Loo, Corewell Health East Resident
• Mitchell Schwocho, Corewell Health East Resident
• Athanasios Rempakos, Corewell Health East Resident
• Zin Tarakji, Corewel Health East Resident
• Parvathy Ravi Sankar, Corewell Health East Fellow
• Elvis Cami, Corewell Health East
• Thomas A. Schwann, Corewell Health East

Document Type

Conference Proceeding

Publication Date

4-7-2026

Publication Title

Journal of the American College of Cardiology

Abstract

BACKGROUND Prosthetic valve endocarditis (PVE) carries high morbidity and is frequently complicated by periannular extension. Aortic root abscess may progress to pseudoaneurysm or fistula, typically involving a single chamber. Dual atrial fistulae with multivalvular involvement are exceedingly rare. CASE A 76-year-old male with a bioprosthetic aortic valve implanted in 2014 presented with fever, dyspnea, shock, and new murmur. Initial transesophageal echocardiography (TEE) revealed a dilated aortic root with abscess, severe aortic regurgitation, a fistulous tract connecting the left cusp to left atrium, and vegetations on the mitral and tricuspid annuli. Closer inspection revealed a subtle but crucial additional finding: a second fistula connecting the right cusp to the right atrium. The patient underwent aortic root replacement with closure of both fistulae and repair of the mitral and tricuspid valves with excellent results. Blood cultures were negative, but intraoperative tissue culture grew Bacillus species. DECISION-MAKING PVE predisposes to abscess and fistula due to annular suture line vulnerability. Dual aorto-atrial fistulae from a dilated root, including one at the tricuspid annulus, together with concurrent mitral and tricuspid annular vegetations, represent an extraordinarily rare constellation. Echocardiography, particularly TEE, is essential for preoperative diagnosis and planning. Early surgical intervention is lifesaving, allowing both radical debridement and multivalvular repair. CONCLUSION Prosthetic valve endocarditis is more likely to be associated with complications compared to native valve endocarditis. We present a rare case of bioprosthetic aortic root abscess with dual atrial fistulae and multivalvular involvement requiring complex surgical repair. Close examination of TEE and CT imaging are crucial for pre-operative planning. Early recognition and operative management are critical for survival.

Volume

87

Issue

13 Suppl

First Page

A1884

Comments

American College of Cariology 75th Annual Scientific Session & Expo, March 28-30, 2026, New Orleans, LA

Last Page

A1884

Recommended Citation

Abdalaziz MH, Mohama DA, Van Loo AM, Schwocho M, Rempakos A, Tarakji Z, et al. [Sankar PR, Cami E, Schwann TA]. A root with two exits: bioprosthetic aortic root abscess with dual aorto-atrial fistulae. J Am Coll Cardiol. 2026 Apr 7;87(13 Suppl):A1884. doi:10.1016/j.jacc.2026.02.4692

DOI

10.1016/j.jacc.2026.02.4692