Abstract

Background: Aortic root abscess (ARA) is a well-known complication of aortic valve endocarditis and can affect both the native and prosthetic valves. ARA can commonly present with conduction abnormalities such as heart blocks. The abscess can weaken the aortic wall and lead to development of a pseudoaneurysm with eventual rupture and creation of aorto cavitary fistula (ACF). Case summary: A 57-year male with a history of aortic valve replacement presented as symptomatic complete heart block. The patient was found to have aortic root abscess and pseudoaneurysm formation, with fistulous connection between aortic annulus and aortic root. Multimodality imaging established the diagnosis followed by complex surgical repair. Discussion: ARA and ACF is rare and is reported to be present in 5.8% of patients with prosthetic valve and 3.8% in native valve. Prompt diagnosis and treatment of this condition is crucial with the use of multimodality imaging. TEE with color Doppler can help establish the fistulous connection of the abscess cavity with the cardiac chambers. Aortic root ring sign is seen on PET/CT in the presence of ARA. Urgent surgical correction with appropriate antibiotics is needed to prevent further complications.