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Concept 2: Extra-aortic invasion of native valve endocarditis is localized.

Concept 2: Extra-aortic invasion of native valve endocarditis is localized. Figure e2. Figure e2, A1 . Pre-invasion: Superficially damaged endocardium in triangle beneath right– noncoronary cusp commissure, but still not breaking aortic wall (arrow). RCS. NCS.

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Concept 2: Extra-aortic invasion of native valve endocarditis is localized.

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  1. Concept 2: Extra-aortic invasion of native valve endocarditis is localized. Figure e2

  2. Figure e2, A1. Pre-invasion: Superficially damaged endocardium in triangle beneath right–noncoronary cusp commissure, but still not breaking aortic wall (arrow). RCS NCS NCS=noncoronary sinus, RCS=right coronary sinus

  3. Figure e2, A2. On echo from same patient, no invasive disease is seen.

  4. Figure e2, B1. Invasion with cellulitis outside aortic wall: Invasion might not be obvious. Infected aortic valve with rheumatic disease displaying small vegetations on right–left commissure (arrow). Immediate appearance did not suggest invasion or extra-aortic extension. RCA LCA LCA=left coronary artery, RCA=right coronary artery

  5. Figure e2, B2. Same aortic valve after peeling off aortic wall discloses true extent of extra-aortic invasion (arrow). Incomplete debridement is associated with a high probability of recurrent infection. RCA LCA LCA=left coronary artery, RCA=right coronary artery

  6. Figure e2, B3. Same patient. The echo did not disclose the invasive disease.

  7. Figure e2, C1. Invasion with extra-aortic cellulitis (arrow): Subpulmonary extension after unroofing and complete debridement of infected and necrotic tissue. Ready for reconstruction. PT RCA LVOT LCA LCA=left coronary artery, LVOT=left ventricular outflow tract, PT=pulmonary trunk, RCA=right coronary artery

  8. Figure e2, C2. Echo of subpulmonic abscess.

  9. Figure e2, D. Subpulmonary invasion with abscess formation: Abscess cavity early after spontaneous rupture (arrow). Lateral trigone is marked with stay suture. Lateral trigone and mitral anulus are detached in the corner, requiring recognition and tension-free reconstruction! MV LCA LCA=left coronary artery, MV=mitral valve

  10. Figure e2, E. Invasive disease healed by antibiotics, leaving an extra-aortic horseshoe-shaped pseudoaneurysm (arrows). Aortic root has been laid open by complete debridement and pulmonary autograft harvest. Initial stitches have been placed to begin suturing autograft to base of mitral valve (MV). RVOT MV RVOT=right ventricular outflow tract

  11. Figure e2, F. Invasion caused by Staphylococcus aureus: Vegetations underneath right–noncoronary commissure with perforation (arrow and probe) to pericardium, resulting in death from tamponade.

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