Lost but not gone: successful management of a pulmonary valve bioprosthesis embolization

A 20-year-old man presented with a 1-month history of fever, vomiting, and nocturnal sweats. His medical history included double-outlet right ventricle with pulmonary stenosis, surgically corrected by a Rastelli procedure eight years earlier, with an uneventful postoperative course until the current presentation. Echocardiography demonstrated new-onset pulmonary regurgitation (see Supplementary data online, Video S1), comparing the immediate postoperative transthoracic echocardiogram (A) with the current transoesophageal echocardiogram (B). Fluorodeoxyglucose positron emission tomography/computed tomography revealed abnormal radiotracer uptake in the right interlobar pulmonary artery branch (see Supplementary data online, Video S2), raising suspicion for endocarditis-related embolization of the pulmonary valve bioprosthesis, subsequently confirmed by computed tomography angiography (CTA). Comparative CTA images obtained postoperatively (A, B) and at presentation (C, D) are shown. Postoperative imaging demonstrated a right ventricle–to–pulmonary artery (RV–PA) conduit containing a bioprosthetic valve (arrowhead in A), with no abnormalities in the right interlobar branch (hollow arrow in B). Current imaging revealed absence of the valvular component within the RV–PA conduit (hollow arrowhead in C) and migration of the bioprosthetic valve to the right interlobar branch (arrow in D).