Abstract
This is the case of a patient in their 30s who is known to have a prosthetic mitral valve replacement and a cardiac pacemaker that presented to the hyper-acute stroke unit with collapse, left-sided dense weakness, back pain, dyspnea, and hypoxia. Investigations showed bilateral areas of intracerebral haemorrhage. Transthoracic echocardiogram (TTE) showed prosthetic mitral valve, atrial and ventricular lead vegetations with severe valvular incompetence due to the valve being markedly thickened with mobile oscillating masses seen on atrial and ventricular sides. The patient was not a candidate for surgical management given a history of continuous intravenous drug use (IVDU) as well as significant risks posed by haemorrhagic stroke and poor previous post-operative compliance. While the patient initially showed improvement with medical management, including appropriate antibiotics, persistent staphylococcus aureus bacteremia remained. Despite ongoing treatment efforts, the patient experienced clinical deterioration and succumbed to their illness from multi-organ failure. This case highlights the challenges in managing infective endocarditis involving prosthetic valves and cardiac devices, particularly in the setting of contraindications to surgical intervention and significant comorbidities. It highlights the need for a multidisciplinary approach to balance the risks of surgical versus medical management in complex cases, as well as the importance of early recognition and tailored therapeutic strategies.