Case Report For reprint orders, please contact: reprints@futuremedicine.com An atypical pseudoaneurysm as complication of prosthetic aortic-valve endocarditis Andrea I Guaricci *, ‡ ,1 , Rita L Musci ‡ ,1 , Delia De Santis 1 , Donatella Argentiero 1 , Luca Sgarra 1 , Concetta Losito 2 , Vito Marangelli 1 , Frida Nacci 1 , Domenico Zanna 1 & Stefano Favale 1 1 Department of Emergency & Organ Transplantation, Institute of Cardiovascular Disease, University Hospital ‘Policlinico’ of Bari, Bari, Italy 2 Department of Cardiac Surgery, Department of Emergency & Organ Transplantation, University Hospital ‘Policlinico’ of Bari, Bari, Italy * Author for correspondence: Tel.: +39 080 557 5720; Fax: +39 080 522 2180; andrea.guaricci@gmail.com ‡ Authors contributed equally Endocarditis of a prosthetic heart valve is a life-threatening condition that is associated with high morbid- ity and mortality. Perivalvular extension in infective endocarditis includes complications such as periannu- lar or intramyocardial abscesses, pseudoaneurysms and fstulae. The incidence of perivalvular extension ranges from 10 to 30% in native valve endocarditis and 30 to 55% in prosthetic aortic-valve endocarditis. Herein, we describe a case of a 66-year-old man who presented endocarditis of a prosthetic aortic valve complicated by infective pseudoaneurysm with localization next to the right coronary sinus of Valsalva. Moreover, we underscore the importance of the diagnostic imaging tools options and surgical timing. First draft submitted: 22 April 2017; Accepted for publication: 15 September 2017; Published online: 16 October 2017 Keywords: aortic fstula • computed tomography • echocardiography • endocarditis • perivalvular complications • prosthetic valve • surgery Infective endocarditis (IE) is defined as an infection of the endocardial surface of the heart, which may involve one or more heart valves (native valve endocarditis [NVE], prosthetic valves endocarditis [PVE] and implanted devices). Urgent surgical treatment is often related to the occurrence of severe complications including pseudoaneurysms and fistula. The pharmacological approach and the complete treatment of such complications must be made as quickly as possible, even if those have to be tailored at the level of individual patient. This paper reports a rare case of infective pseudoaneurysm with localization next to the right coronary sinus of Valsalva following PVE. Moreover, it underscores the importance of the diagnostic imaging tools options and surgical timing. Case description The patient being discussed was a 66-year-old man with a family history of ischemic heart disease and a medical history of chronic obstructive pulmonary disease and radical left nephrectomy for renal cell carcinoma. He was smoker with no other cardiovascular risk factors. 6 years previously, the patient underwent biological prosthetic aortic valve (Mitroflow 23, Sorin Group, Saluggia, Italy) implantation for treating severe aortic regurgitation due to IE. 2 months before the arrival to our institute, he had been hospitalized at the Medicine Department because of fever incurrence, dyspnea and generalized bone pain. 30 days before the patient was admitted to the Pulmonology Department owing to pneumonia with pleural effusion, he had been started on cefditoren (cephalosporin, third generation). The patient was admitted to our hospital due to worsening dyspnea and orthopnea in the previous 3 days. At admission, he was apyretic, in New York Heart Association (NYHA) class III and referred shortness of breath. At clinical examination, the heart rate was 93 bpm, the blood pressure 115/60 mmHg and arterial oxygen saturation 96%. Cardiac examination revealed a variable intensity of S1, early diastolic murmur at second left intercostal space and a grade 2/6 ejection systolic murmur in the aortic area. Crackles were audible in the lower third of the pulmonary fields. Laboratory tests showed normal leucocyte count (7.140/ml with 65.4% neutrophilis), moderate anemia (Hb: 9.2 g/dl with hematocrite 30.5%) and mild increasing of systemic inflammation markers (C-reactive protein: 10.2217/fca-2017-0032 C  2017 Future Medicine Ltd Future Cardiol. (Epub ahead of print) ISSN 1479-6678