Aorto-right ventricular fistula: a rare complication of Abiotrophia Endocarditis

A 41-year-old African male presented with worsening dyspnea and cachexia concerning for congestive heart failure. Transesophageal echocardiogram revealed a large mass attached to the aortic valve leaflet, mass attached to the flail anterior mitral valve leaflet, severe pulmonary hypertension and dilatation of the aortic root along with fistula between the right coronary aortic cusp and the right ventricular (RV) outflow tract. Blood cultures grew Abiotrophia Defectiva (AD) sensitive to vancomycin. Patient underwent emergent surgical closure of aorto RV fistula and aortic root replacement along with pulmonary and mitral valve replacement. Endocarditis caused by AD has been reported to result in heart failure, septic embolization and destruction of the valve despite use of appropriate antibiotics. To our knowledge, this is the only case of AD endocarditis without any identified entrance route; requiring replacement of pulmonary, mitral and aortic valve due to extensive valvular damage and large vegetations.