25099              AORTIC VALVE PROSTHESIS, SURROUNDING HAEMATOMA, SEPTICAEMIA

The patient was a man aged 54.  Twelve years previously the aortic valve was surgically split.  Five years later an aortic valve prosthesis was inserted, with internal fixation of a pacemaker.  On the last occasion there was a 3-day history of nausea, vomiting and backache, with a high swinging fever.  Blood culture grew staphylococcus aureus for which he was given high doses of intravenous antibiotics, with good recovery initially.  On the 7th day there was sudden deterioration with haematuria and neurological symptoms.  Anticoagulant therapy (Warfarin) had been stopped two days previously when the prothrombin was 9%.  There was left homonymous hemianopia and left hemiplegia.  Three days later he became comatose and died.  At postmortem there was a large cerebral haemorrhage apparently originating from the region of the right basal ganglia and extending back to the right occipital pole and into the 3rd ventricle.  The heart weighed 680 gms.

The specimen shows the aortic prosthesis in situ with some antemortem thrombosis around its base.  From this point an infected haematoma distends the tissues at the root of the aorta and has caused considerable widening of the interatrial septum to a thickness of some 3 cms.  Inferiorly the haematoma is limited by the mitral valve ring and the mitral cusp appears not grossly abnormal.  There is some hypertrophy of the muscle and of the left atrium and of the left ventricle.  A line of firm sutures covered by endothelium can be seen on the posterior wall of the aorta 3 cms above the prosthesis.