Clinical Case Database / Category: Patient Management

Endocarditis & mitral valve prolapse

Publication details

Robert Spooner, Rohin Francis, Leisa Freeman
Foundation Years Journal, volume 8, issue 2, p.32 (123Doc Education, London, February 2014)


A 63 year-old man with a known diagnosis of mitral regurgitation had been referred for outpatient mitral valve repair. Whilst on the waiting list for surgery, he presented with weight loss and night sweats. Echocardiography showed severe mitral regurgitation secondary to mitral valve prolapse and a large vegetation adherent to his mitral valve. Blood cultures subsequently grew a Strep Mitis organism and he was started on IV antibiotics. This man did not have features of congestive cardiac failure, and traditional management may have taken a conservative approach; e.g. prolonged course (days to weeks) of IV antibiotic administration prior to surgical intervention. However, in view
of recent evidence showing a reduction in mortality when early cardiac valve surgery is performed in patients with large endocarditic vegetations (1), urgent surgery was arranged and he underwent mitral valve replacement with a good result.

This case highlights the diagnostic challenges of endocarditis, and reflects on emerging evidence supporting early surgical intervention for endocarditic patients with large (>10mm) vegetations (1).

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Robert Spooner

Department of Cardiology
Norfolk and Norwich University Hospital
Colney Lane, Norwich, NR4 7UY, UK

Rohin Francis

Department of Cardiology
Norfolk and Norwich University Hospital
Colney Lane, Norwich, NR4 7UY, UK

Leisa Freeman

Department of Cardiology
Norfolk and Norwich University Hospital
Colney Lane, Norwich, NR4 7UY, UK


1. Kang D, Kim J, Kim S, Joo Sun B, Kim D, Yun S, Song J, Choo S, Chung C, Song J, Lee J and Sohn D. Early versus conventional treatment for infective endocarditis. The New England Journal of Medicine 2012;366:2466-73.
2. Li JS, Sexton DJ, Mick N, Nettles R, Fowler VG Jr., Ryan T, Bashore T, Corey GR. Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clin infect Dis 2000; 30: 633.
3. AHA Scientific Statement. Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of complications. Circulation. 2005;111:e394-e433.
4. Tornos P et al. Infective Endocarditis in Europe: Lessons from the EuroHeart Survey. Heart. 2005; 91:571-575.
5. Habib G, Hoen B, Tornos P, et al. Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009): the Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of the European Society of Cardiology (ESC). Eur Heart J 2009;30:2369-413.
6. Holenarasipur R. Vikram, MD; Joan Buenconsejo, MPH; Rodrigo Hasbun, MD; Vincent J. Quagliarello, MD. Impact of valve surgery on 6-month mortality in adults with complicated, left sided native valve endocarditis. JAMA 2003;290(24):3207-3214.
7. Vivian H. Chu, MD; Christopher H. Cabell, MD; Daniel K. Benjamin Jr, MD, MPH, PhD; Erin F. Kuniholm, MD, MPH; Vance G. Fowler Jr, MD, MHS; John Engemann, MD; Daniel J. Sexton, MD; G. Ralph Corey, MD; Andrew Wang, MD. Early predictors of in-hospital death in infective endocarditis. Circulation 2004;109:1745-1749.
8. Mylonakis E, Calderwood SB. Infective endocarditis in adults. The New England Journal of Medicine 2001; 345(18):1318-30.
9. European Society of Cardiology (ESC) guidelines on infective endocarditis 2009. (http://www. Accessed 29th November 2012.
10. Murdoch DR, Corey GR, Hoen B, Miro JM, Fowler VG Jr, Bayer AS, Karchmer AW, Olaison L, Pappas PA, Moreillon P, Chambers ST, Chu VH, Falco V, Holland DJ, Jones P, Klein JL, Raymond NJ, Read KM, Tripodi MF, Utili R, Wang A, Woods CW, Cabell CH. Clinical Presentation, etiology and outcome of infective endocarditis in the 21st century: the International Collaboration on Endocarditis-Prospective Cohort Study. Arch Intern Med 2009;169:463-473.
11. Gould FK, Denning DW, Elliot TSJ, Foweraker J, Perry JD, Prendergast BD, Sandoe JAT, Spry MJ and Watkin RW. Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults: a report of the Working Party of the British Society for Antimicrobial Chemotherapy. Journal of antimicrobial therapy 2012; 67: 269-289.
12. Houpikian P, Raoult D, Diagnostic methods. Current best practices and guidelines for identification of difficult-to-culture pathogens in infective endocarditis. Cardiol Clin 2003; 21: 207-17.
13. Prendergast B; Tornos P. Surgery for Infective Endocarditis: Who and When? Circulation 2010; 121:1141-1152.


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About the Clinical Cases Database

T​he Foundation Years Clinical Cases Database is​ a selection of 600 peer-reviewed clinical cases in the field of patient safety and clinical practice, specifically focused on the clinical information needs of junior doctors, based around the Foundation Year Curriculum programme (MMC). The cases have been chosen to align with the Foundation Year Curriculum.

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