Aortic valve aneurysm: a result or reason?

A 37-year-old patient had a cerebrovascular accident and according to history and physical examination, emboli secondary to infective endocarditis (IE) was suspected. He had no notable previous medical history. His tomography showed an ischemic area in the left cerebral hemisphere. Transthoracic echocardiography revealed a mild to moderate aortic regurgitation. On parasternal long-and short-axis views, a small mass was found attached to the left coronary cusp of the aortic valve. It resembled a cystic mass rather than a vegetation (Fig. 1). On transesophageal echocardiogram, the cystic mass was actually found to be the aneurysmatic left coronary cusp (Fig. 2, Video 1, 2. See corresponding video/movie images at www.anakarder.com). No solid lesion was discovered. The cusp prolapsed into the left ventricular outflow tract (LVOT) during diastole. The antibiotherapy was started after blood samples were drawn. Methicillin-sensitive staphylococcus was cultured from three samples. According to modified Duke’s criteria, a possible diagnosis of IE was established (positive blood culture for typical microorganism, temperature >38°C and major arterial emboli). On follow-up, aortic regurgitation worsens and acute heart failure developed. He was referred for surgery. On operation, the left coronary cusp was found to be markedly enlarged, thin and aneurysmatic but no vegetation was found. The valve was replaced with a prosthesis and the postoperative follow-up was uneventful. One may wonder if the prevailing valvular aneurysm is a risk factor for IE rather than a complication of it. As we do not know whether the patient had any previous valvular disease or not, we could not answer this question definitely. As valvular aneurysms are almost never seen in daily practice and the coexistence with infective endocarditis in literature, it is reasonable to assume that they are the consequences of IE.