C  2008, the Authors Journal compilation C  2008, Wiley Periodicals, Inc. DOI: 10.1111/j.1540-8175.2008.00776.x Fungal Ascending Aortic Aneurysm after Cardiac Surgery Stella Brili, M.D., ∗ Constantinos Rokas, M.D.,† Konstantinos Tzannos, M.D., ∗ John Barbetseas, M.D., ∗ Maria Pirounaki, M.D.,‡ and Christodoulos Stefanadis, M.D. ∗ ∗ Department of Cardiology, “Hippocration” Hospital, University of Athens, Athens, Greece; †Cardiosurgery Department, “Atticon” Hospital, University of Athens, Athens, Greece; and ‡Department of Internal Medicine, “Hippocration” Hospital, Athens, Greece A 52-year-old diabetic male was admitted due to 1-month history of fever, fatigue, and mild shortness of breath. Three months prior to admission, he had undergone aortic valve replacement, with a pros- thetic one, because of streptococcus viridans endocarditis complicated by severe aortic regurgitation. Transesophageal echocardiogram revealed prosthetic valve endocarditis with dehiscence of the aortic valve and an abscess cavity extending from the aortic root into the ascending aorta. Blood cultures and serology were negative. Due to clinical deterioration, despite antibiotic therapy, the patient was reoperated on and the aortic valve and ascending aorta were replaced with a homograft. Valve culture grew Aspergillus flavus. This case is an example of a rare but of increasing frequency complication after cardiac surgery. Considering the high mortality from this complication, early recognition is of paramount importance. (ECHOCARDIOGRAPHY, Volume 26, January 2009) endocarditis infective, aorta, aortic ring abscess, prosthetic valve, cardiac surgery, aortitis Case Report A 52-year-old diabetic male was admitted to our hospital because of fever, fatigue, and mild shortness of breath for 1 month. Three months prior to the present admission, he suffered na- tive aortic valve endocarditis due to penicillin- sensitive streptococcus viridans. The infection was complicated by severe aortic insufficiency and he underwent valve replacement with a bioprosthetic valve. At discharge, he was in good clinical condition and he received antibi- otic treatment for the next 4 weeks. At present admission the patient was pale, hemodynamically stable, and his temperature was 38.5 ◦ C. A 3/6 systolic and a 3–4/6 diastolic murmur could be heard at the second right in- tercostal space parasternally and on the left sternal border, respectively. Transesophageal echocardiogram revealed prosthetic valve en- Address for correspondence and reprint requests: Stella Brili, M.D., Department of Cardiology, University of Athens, “Hippocration” Hospital, 114 Vas. Sophias Av- enue, Athens, Greece. Fax: +30-210-7485039; E-mail: stlbrili@gmail.com docarditis with dehiscence of the aortic valve and an abscess cavity extending from the aor- tic root into the ascending aorta (Figs. 1 and 2). The patient was put on broad-spectrum an- tibiotics with no visible improvement. Multi- ple blood cultures prior to initiation of antibi- otic treatment as well as serology for causes of culture-negative endocarditis were negative. Due to persistent fever and worsening clini- cal condition, the patient was operated on and the aortic valve and ascending aorta were re- placed with a homograft with concurrent reim- plantation of coronary arteries. Valve culture grew Aspergillus flavus. The patient was subse- quently put on liposomal amphotericin B with gradual improvement (Fig. 3). There are several case reports of As- pergillus endocarditis and aortitis after car- diopulmonary bypass. Actually, the prevalence of such infections is increasing. 1–3 However, es- tablishing the diagnosis and treatment remain difficult and Aspergillus endocarditis and aor- titis carry a poor prognosis. 1–4 Conditions that predispose to Aspergillus en- docarditis and aortitis include immunosuppr- ession, implantation of intracardiac prosthetic 84 ECHOCARDIOGRAPHY: A Jrnl. of CV Ultrasound & Allied Tech. Vol. 26, No. 1, 2009