very old patient was admitted with prolonged weakness, subfebrile fever and dyspnoea. The patient was in 3 (!) other hospitals before in the last months with unclear elevated markers of inflammation. You could hear a diastolic mild heart murmur beside the typical mumur of aortic prosthesis. Markers of inflammation was very high (CRP > 150 mg/l; normal range in our hospital 2,5; leucocytes > 14.000)
in TTE (not shown) you could see a severe degenerated mitral valve with high grade mitral valve insufficiency (Carpentier IIIa) and a moderat mitral stenosis, aortic valve prosthesis (double disc) with normal transprothetic gradient and velocity, and a high grade tricuspid valve insufficiency with elevated pulmonary pressure (probably secundary caused by mitral insufficíency). There was a suspicion of small excentric insufficiency beside the aortic valve prosthesis, so we decided to do the TEE.
Here I saw the typical picture of a paraprthstic abscess with flow into the LVOT.