atrioventricular node and His bundle Figure e4 Figure e4 A Echo showing aortic rootright atrial fistula Figure e4 B1 Native valve endocarditis with sepsis and heart block Huge ID: 1038444
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1. Concept 4: Heart block is caused by bacterial destruction of the atrioventricular node and His bundle.Figure e4
2. Figure e4, A. Echo showing aortic root–right atrial fistula.
3. Figure e4, B1. Native valve endocarditis with sepsis and heart block: Huge vegetations on aortic valve cusps (black arrow) and bacterial invasion and periaortic phlegmone and cellulitis (blue arrow). RAPTPT=pulmonary trunk, RA=right atrium
4. Figure e4, B2. Native valve endocarditis with sepsis and heart block: Looking into right atrium (RA) reveals vegetations and perforation (arrow) close to Koch triangle and atrioventricular node. RATVCSCS=coronary sinus, TV=tricuspid valve
5. Figure e4, B3. After complete debridement of infected and necrotic tissue, proximity of infection to atrioventricular node is seen. Also notice that a portion of the right coronary artery is laid bare (arrow). We have not seen destruction or thrombosis of a coronary artery even when it is surrounded by infection. TVLVOTCSCS=coronary sinus, LVOT=left ventricular outflow tract, TV=tricuspid valve
6. Figure e4, B4. Use of pericardium (arrow) to reconstruct aorto–right atrial interface following debridement. RCALVOTLVOT=left ventricular outflow tract, RCA=right coronary artery
7. Figure e4, C1. Prosthetic valve endocarditis with sepsis and heart block: Infected mechanical prosthesis with vegetations on sewing ring (arrow).
8. Figure e4, C2. Same patient with prosthetic valve endocarditis and sepsis and heart block: Perforation visible in right atrium (RA; arrow).TVRACSCS=coronary sinus, TV=tricuspid valve
9. Figure e4, C3. After debridement, destruction in location of atrioventricular node is seen. This infection has worked its way around the aorta counterclockwise over an extended period, displaying a pseudoaneurysm stage anteriorly and an active cellulitis stage posteriorly and into right atrium. Left ventricular outflow tract (LVOT) is intact and ready for reconstruction.RCALCALVOTCFBCSCFB=central fibrous body, CS=coronary sinus, LCA=left coronary artery, RCA=right coronary artery
10. Figure e4, D1. Advanced aortic prosthetic valve endocarditis with fistula to right atrium (arrow) marked by a vegetation.
11. Figure e4, D2. Same patient’s echo showing periaortic abscess with fistula from left ventricular outflow tract to right atrium.
12. Figure e4, E1. Allograft endocarditis with heart block: Endocarditis with sepsis and heart block in patient with a history of aortic allograft root replacement. Allograft cusps are not affected, but vegetations are present on proximal aortic suture line (arrow). LCARCALCA=left coronary artery, RCA=right coronary artery
13. Figure e4, E2. Same patient: Cauliflower vegetation (arrow) next to atrioventricular node marking penetration into right atrium. TVTV=tricuspid valve
14. Figure e4, E3. Same cauliflower vegetation (arrow) next to atrioventricular node after opening aortic and right atrial (RA) walls down to vegetation.TVRALVOTLVOT=left ventricular outflow tract, TV=tricuspid valve
15. Figure e4, E4. Complete removal of allograft and debridement discloses extent of peri-allograft infection, which extends from right coronary artery (RCA) counterclockwise to membranous septum and atrioventricular node (arrow). Root is ready for reconstruction.RCALCACSTVLVOTRACS=coronary sinus, LCA=left coronary artery, LVOT=left ventricular outflow tract, RA=right atrium, TV=tricuspid valve