Surgical Explantation of a Balloon-Expandable Transcatheter Aortic Valve With Aortic Root Preservation for Prosthetic Valve Endocarditis: A Case Report

Abstract

Infective endocarditis following transcatheter aortic valve implantation represents an increasingly recognized and devastating clinical entity characterized by severe morbidity, high mortality, and formidable surgical complexity. As indications for transcatheter aortic valve procedures expand toward younger and lower-risk patient cohorts, late-onset endocarditis poses significant therapeutic dilemmas. Surgical management is technically challenging due to dense tissue integration, neointimal proliferation, and complete endothelialization of the expanded metallic frame into the aortic wall and subvalvular structures. We report the case of a 77-year-old male with a history of transfemoral transcatheter aortic valve implantation (TAVI) and permanent dual-chamber pacemaker placement who presented with late-onset Enterococcus faecalis infective endocarditis. The patient developed severe prosthetic valve dysfunction alongside secondary severe functional mitral regurgitation. Comprehensive multiplanar and three-dimensional transesophageal echocardiography identified extensive mobile vegetations significantly obstructing the prosthetic lumen. The patient successfully underwent urgent open cardiac surgery, consisting of complete explantation of the heavily endothelialized metallic stent frame via meticulous peri-stent sharp dissection, biological aortic valve replacement with aortic root preservation, and ring mitral annuloplasty. The postoperative course was uneventful, and the patient completed six weeks of targeted intravenous antimicrobial therapy with clinical and echocardiographic improvement. Surgical explantation with preservation of the native aortic root may represent a feasible therapeutic strategy in selected patients with TAVI-associated infective endocarditis requiring surgical intervention, particularly in the presence of severe prosthetic valve dysfunction, extensive vegetation burden, or associated multivalvular disease.