**Introduction/Hypothesis:**
Bentall procedure is a complex cardiac surgical intervention involving the replacement of the aortic root and the ascending aorta with or without the native aortic valve. It is performed for various pathologies of the aortic valve – stenosis or regurgitation, type A aortic dissection or aneurysm. Complications such as graft infections are seen in <2% of the patients undergoing this procedure. This case describes the clinical course and radiological features in a patient with delayed Bentall graft infection, endocarditis and pseudoaneurysm formation.

**Methods**
A 60-year-old female with a past medical history of bicuspid aortic valve with severe aortic stenosis and ascending aorta aneurysm status post Bentall procedure (with On-X mechanical valve and hemiarch replacement with Dacron graft 3 years prior) who presented to the emergency room with complaints of chest pain, shortness of breath and low-grade fevers and lower extremity edema.
On examination, the patient was afebrile (36.8 °C), tachycardic (112 beats/minute), and tachypneic (23 cycles/minute). She had a 2+ pitting edema, mid-line sternotomy scar, systolic murmur with a metallic click, Osler’s nodes and wheezing. CTA chest showed perivalvular abscess (Figure 1). Transesophageal echo confirmed a large multiloculated posterior aortic root abscess with evidence of pseudoaneurysm (Figure 2). The patient’s antibiotics were modified to nafcillin, gentamicin and rifampin.
The patient underwent a redo-Bentall procedure with Rifampin soaked On-X mechanical valve and Dacron graft. It was complicated by the development of a complete heart block. A permanent pacemaker was implanted which she tolerated well. The patient was discharged with Nafcillin 2 g intravenously every 4 hours, Rifampin 450 mg by mouth twice a day for a total of 6 weeks followed by Cefadroxil 1 g twice a day for life.

**Results**
Delayed complications of Bentall procedure include endocarditis, hemorrhage, thromboembolism and valve related events needing management with re-operation or long-term antibiotics. Bentall graft infection is a rare and severe complication. As seen in our patient, majority of the infections have a late onset and are caused by gram positive bacteria. A combination of various imaging modalities such as transesophageal echo, CT angiography of the thorax and PET CT may be necessary for accurate diagnosis. When identified, corrective surgery or prolonged antibiotics in patient who cannot undergo surgery are options for treatment. Appropriately managed patients have about 80% chance of recovery.

**Conclusion**
The diagnosis of Bentall graft infections is challenging and requires high clinical suspicion and supportive radiological features. Imaging findings from various modalities is crucial for timely diagnosis and appropriate management in patients.



Delayed graft infection and pseudoaneurysm after a Bentall procedure: A case report