A 40-year-old male presents with light-headedness and fever.
He has a significant cardiac history including congenital heart disease with coarctation of the aorta and a ventricular septal defect (VSD) repaired as an infant. He subsequently required bioprosthetic AVR and thoracic aortic aneurysm repair.
On arrival his vitals include HR 44, BP 95/62, temp 38.0, RR 24, sats 96% RA
ECG on presentation
Describe and interpret his ECG
We see regular p waves, at a rate of 75, and regular broad complex QRS complexes, at a rate of 44. There is no association between the p waves and the QRS complexes.
These features indicate complete heart block with a junctional escape rhythm.
A CT scan of the chest is performed
Describe and interpret these images
The case demonstrates findings of aortic root abscess.
It is most commonly found in patients with prosthetic valves and aortic root repair and/or a complication of infective endocarditis.
The CT shows multiple irregular saccular contrast filled outpouchings at the aortic root. This is due to mycotic aneurysms caused by infection. The CT also shows abnormal soft tissue density surrounding the aortic root which is due to inflammation of the tissues.
There is calcification of the graft and the tissue valve.
An important complication to look for, not seen here, is fistula formation. This can occur between the aorta and other cardiac chambers or mitral annulus.
Aortic root abscess
Aortic root abscess is a potential (rare) complication of aortic valve replacement.
Infection can affect the adjacent cardiac conduction tissues, leading to conduction abnormalities such as heart block.
Definitive management, is urgent surgical debridement and repair by the cardiothoracic team.
In the emergency setting, patients will receive broad spectrum antibiotics (flucloxacillin, vancomycin and gentamicin).
Management of the bradycardia is essential. This patient was commenced on an isoprenaline infusion.
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Emergency Medicine Education Fellow at Liverpool Hospital NSW. MBBS (Hons) Monash University. Interests in indigenous health and medical education. When not in the emergency department, can most likely be found running up some mountain training for the next ultramarathon.
Sydney-based Emergency Physician (MBBS, FACEM) working at Liverpool Hospital. Passionate about education, trainees and travel. Special interests include radiology, orthopaedics and trauma. Creator of the Sydney Emergency XRay interpretation day (SEXI).