The prosthetic valve, fever and a longer PR interval

For three weeks he has had fatigue, sweats and intermittent shivering. He has not measured his temperature. Over the last four days he has become breathless climbing stairs. There is no breathlessness at rest, current chest pain, syncope or haemoptysis.

He felt briefly light-headed this morning but did not collapse. Ask about confusion, reduced urine output, rigors, rapidly worsening breathlessness and haemodynamic symptoms because these determine whether the consultation must stop for immediate resuscitation.

He has a new constant ache between the shoulder blades, worse at night and not clearly movement-related. There is no limb weakness, sensory level, bladder disturbance or saddle anaesthesia. Yesterday he noticed ten minutes of clumsiness in his right hand, now resolved; he did not seek help.

There is no painful cold limb, persistent abdominal pain or visual loss. The transient focal deficit and back pain may represent embolic or metastatic complications and must not be dismissed as unrelated symptoms.

A mechanical aortic valve was implanted six years ago for bicuspid aortic stenosis. He has had no previous endocarditis. Four weeks ago a painful lower molar fractured; he has not seen a dentist. He also had dysuria treated remotely with trimethoprim for three days, then co-amoxiclav for five days. No urine culture was taken.

Ask about recent dental work, skin infection, intravenous lines, invasive procedures, healthcare exposure, tattoos, injected drugs and animal or occupational exposures. He has eczema with cracked skin on both hands but no injected drug use or recent admission. Antibiotics before cultures may reduce microbiological yield; they do not make infection unlikely.

Warfarin with a usual target set by the anticoagulation service, bisoprolol 2.5 mg daily and atorvastatin 20 mg nightly. He has taken ibuprofen most days for back pain. His INR yesterday was 4.8. Do not independently stop, reverse or bridge anticoagulation without defining bleeding, neurological findings, valve thrombosis risk and the procedural plan.

He owns a small shop and fears losing income. His wife died after a long intensive-care admission, so the phrase heart surgery makes him shut down. His immediate question is whether another oral antibiotic would let him go home.

Alert but tired. Temperature 38.3°C, pulse 104/min and regular, BP 104/62 mmHg, respiratory rate 22/min and oxygen saturation 95% on air. Capillary refill is three seconds; urine output has not been measured. NEWS2 supports escalation but does not diagnose the cause or replace clinical judgement.

Repeat observations, obtain intravenous access and assess ABCDE. Hypotension, altered consciousness, hypoxaemia, pulmonary oedema or worsening perfusion would trigger immediate sepsis management and critical-care support while diagnostic samples are obtained if this does not delay treatment.

There is a crisp mechanical second sound and a new early diastolic murmur at the left sternal edge. JVP is not elevated; there are fine bibasal crackles but no peripheral oedema. Peripheral pulses are present and symmetrical.

A new regurgitant murmur and early congestion raise concern for prosthetic dysfunction or peri-valvular infection. The absence of dramatic heart failure does not justify routine outpatient investigation. Compare with previous examinations and echocardiograms rather than claiming the murmur is definitely new from one assessment.

Inspect hands, nails, skin and eyes without turning peripheral stigmata into a diagnostic checklist. He has cracked eczema and two painless erythematous macules on the left sole; there are no splinter haemorrhages or painful finger nodules. Absence of classic signs does not exclude endocarditis.

Perform a focused neurological examination before anticoagulation or operative decisions: speech, visual fields, cranial nerves, limb power, sensation, coordination and gait if safe. There is subtle right pronator drift. Examine the spine for focal tenderness and neurological compromise; lower thoracic percussion tenderness is present without motor, sensory or sphincter deficit.

Examine the mouth with consent, skin, cannula sites, abdomen for splenic tenderness or organomegaly, and limbs for acute ischaemia. The fractured molar has surrounding gingival inflammation; there is no drainable facial swelling. The abdomen is soft without focal tenderness.

Dental disease is a possible portal, not proof of causation. Do not arrange dental intervention before the cardiac and microbiology plan is coordinated, particularly in a patient who is anticoagulated and may need urgent surgery.

Obtain three sets of peripheral blood cultures from separate venepunctures before new antibiotics when this can be done promptly. Label sites and times; do not draw every bottle through one existing cannula. Send full blood count, CRP/ESR, renal and liver profiles, coagulation, lactate and urinalysis; add other tests according to complications and antimicrobial planning.

Results: haemoglobin 104 g/L, neutrophils 13.2 × 10⁹/L, CRP 168 mg/L, creatinine 146 micromol/L from a baseline of 88, lactate 2.1 mmol/L and INR 5.1. Microscopic haematuria is present. These support systemic illness and organ involvement but are not diagnostic criteria by themselves.

ECG shows sinus tachycardia with PR 238 ms; a tracing two months ago showed PR 176 ms. Progressive atrioventricular conduction delay in aortic prosthetic-valve infection is a warning of peri-annular extension. Continuous rhythm surveillance and urgent specialist review are required.

TTE shows new moderate-to-severe para-prosthetic aortic regurgitation but no definite vegetation. This does not exclude prosthetic-valve endocarditis. Urgent transoesophageal echocardiography is required when feasible; repeat echo and cardiac CT or nuclear imaging may be needed when prosthetic artefact or discordant findings leave uncertainty.

Transoesophageal echocardiography shows a peri-annular cavity adjacent to the aortic prosthesis with rocking motion and para-prosthetic regurgitation, consistent with locally uncontrolled infection. Gated cardiac CT better defines an aortic-root abscess without fistulation.

Urgent brain imaging is arranged because of the transient focal deficit before major anticoagulation or surgery decisions. MRI spine is requested for focal persistent back pain and shows T8–T9 spondylodiscitis without epidural abscess or cord compression. These complications require coordinated, not fragmented, management.

Two culture sets later grow Enterococcus faecalis; the third remains negative. Susceptibilities are pending. Repeat cultures are required to document clearance. The organism, prosthetic material, renal function, allergy history and local resistance data determine targeted therapy with infection specialists.

Do not invent a one-size-fits-all regimen. If cultures remain negative, review prior antibiotics and involve microbiology early for serology, molecular testing and targeted investigation of fastidious organisms guided by exposure and epidemiology.

This is probable prosthetic-aortic-valve endocarditis with new para-prosthetic regurgitation, evolving conduction disease, acute kidney injury and possible cerebral and spinal complications. The combination suggests peri-annular extension until proved otherwise.

My priorities are physiological stabilisation, correctly timed cultures and antimicrobial treatment, urgent anatomical definition, neurological assessment, anticoagulation planning and immediate Endocarditis Team/cardiac surgical involvement. I would not frame this as a choice between antibiotics now and surgery later; both pathways must be assessed together.

Admit to a monitored setting and contact microbiology/infectious diseases, imaging cardiology and the regional cardiac surgical service now. Start empirical intravenous therapy according to the current local prosthetic-valve pathway after cultures, unless instability makes any delay unsafe; adjust for renal function and then narrow to microbiology results.

The new conduction delay, abscess and prosthetic dehiscence represent locally uncontrolled infection and support urgent surgery. Timing is an Endocarditis Team decision incorporating haemodynamics, neurological imaging, anatomy and operative risk, but MDT involvement is not an excuse for passive referral or vague documentation.

Warfarin management must be agreed urgently with cardiology, cardiac surgery, haematology where needed and the anticoagulation service. The supratherapeutic INR, possible cerebral event and likely invasive procedures increase bleeding risk; the mechanical valve creates thrombosis risk. Record the last dose and examine for bleeding.

Do not start antiplatelet or anticoagulant therapy to prevent septic emboli. Do not reflexively reverse all anticoagulation or prescribe bridging without the neurological and surgical context. If intracranial haemorrhage is found, the balance and operative timing change immediately.

‘Your symptoms may be caused by an infection involving the artificial valve. The first heart ultrasound cannot see every area clearly around a mechanical valve, but it has shown a leak that was not there before. The change on your heart tracing also makes us concerned the infection may have reached tissue beside the valve.’

‘You need hospital treatment now. We will take several blood samples to identify the organism, start intravenous antibiotics promptly and use a more detailed scan to define the valve and surrounding tissue. If there is an abscess or the valve is becoming loose, antibiotics alone may not remove infected material; the heart surgeons need to assess you urgently. I know surgery brings back what happened to your wife. We will explain the likely benefit, material risks, alternatives and what could happen without it, and involve the person you choose.’

Acknowledge the financial concern and involve the clinical team, family/supporter with consent and hospital support services, but do not offer outpatient oral antibiotics as a compromise for unsafe discharge. Explain that the back and neurological symptoms require investigation because infection can affect other sites.

Use teach-back: ask him to explain why three culture sets, detailed valve imaging and an early surgical opinion matter. Document the plan, who has accepted referral and the escalation route for hypotension, breathlessness, chest pain, confusion, focal deficit or conduction deterioration.

Stop the rehearsal and manage ABCDE with critical care, cardiology and cardiac surgery immediately. Obtain cultures if this does not delay treatment, start appropriate intravenous antimicrobials and support perfusion and oxygenation. Acute severe prosthetic dysfunction with refractory pulmonary oedema or shock may require emergency surgery; a routine transfer pathway is no longer adequate.

Urgently involve stroke/neurosurgical, cardiology, surgical and anticoagulation expertise. Reassess reversal, valve-thrombosis risk and the timing of cardiac surgery together. Do not apply a memorised anticoagulation rule or proceed to surgery without defining the haemorrhage, neurological trajectory and haemodynamic necessity.

Maintain the diagnosis if the clinical and imaging probability remains high. Reconstruct antimicrobial exposure, repeat appropriately collected cultures and pursue microbiology-led fastidious-organism and molecular investigation. Tissue obtained at surgery should be sent for culture, histology and molecular testing according to the agreed pathway.

Confirm that he understands the diagnosis, recommended operation, likely benefits, material risks, alternatives and the risk of death, heart failure, embolism and uncontrolled infection without surgery. Explore whether grief, fear, financial pressure or remediable misunderstanding drives the refusal; offer a second opinion and supporter without coercion. Respect an informed refusal, document it and agree the safest antimicrobial, monitoring and escalation plan.

Strong: Elicits prosthetic material, antibiotic exposure, portal, embolic symptoms, back pain, time course and the patient's fears.

Incomplete: Records fever and a valve replacement but misses transient neurology, spinal pain or prior antibiotics.

Unsafe: Accepts recurrent urine infection and offers another oral antibiotic without cultures or cardiac assessment.

Strong: Assesses physiological stability, new valve dysfunction, neurological state, conduction risk and metastatic infection.

Incomplete: Performs a generic cardiovascular examination without interpreting the PR change or extracardiac findings.

Unsafe: Uses absent peripheral stigmata or a non-diagnostic TTE to exclude endocarditis.

Strong: Obtains correctly timed cultures, escalates to TOE/multimodality imaging and starts protocol-led therapy without unsafe delay.

Incomplete: Requests cultures and echo but gives no sequence, ownership or plan for prosthetic artefact and complications.

Unsafe: Delays antibiotics in shock, gives empirical oral treatment, or prescribes a regimen without microbiology and renal context.

Strong: Makes an urgent surgical recommendation and frames anticoagulation as an individualised neurological and procedural risk decision.

Incomplete: Says only ‘discuss at MDT’ and avoids a recommendation or timescale.

Unsafe: Waits for complete heart block, starts anticoagulation to prevent septic emboli, or automatically reverses/bridges without context.

Strong: Explains uncertainty and the need for admission, detailed imaging and possible surgery while addressing work and bereavement-related fear.

Incomplete: Lists tests and treatments but never discovers why he wants to leave.

Unsafe: Promises antibiotics will cure the condition, coerces consent or permits unsafe discharge as a compromise.

A prosthetic valve, systemic symptoms and recent antibiotics create high diagnostic risk even without classic peripheral signs.

Take multiple properly collected cultures before new antibiotics when this does not delay treatment of instability.

A non-diagnostic TTE does not exclude prosthetic-valve endocarditis; TOE and complementary imaging may define peri-annular disease.

New conduction delay can signal extension around the aortic root and should accelerate monitoring, imaging and surgical referral.

Abscess, dehiscence and significant prosthetic dysfunction require an urgent surgical decision alongside—not after—antimicrobial treatment.

Give a 90-second handover to the cardiac surgeon: problem representation, stability, valve, cultures, conduction change, imaging, neurological concern, anticoagulation and your recommendation. Then explain the same plan to David without jargon and use teach-back.