What is the clinical evidence from this study?

Study design: Case Report. Population: Tricuspid valve infective endocarditis due to ESBL producing E.coli with AV block (n=1). Intervention: Epicardial pacing and intravenous ertapenem. Primary outcome: Clinical resolution.

What question did this study set out to answer?

To report a rare case of infective endocarditis caused by ESBL-producing E. coli associated with advanced AV block.

June 27, 2026Journal of Cardiothoracic Surgery0 citationsOpen Access

Tricuspid valve infective endocarditis due to ESBL producing E.coli associated with AV block requiring epicardial pacing: A case report

RSRoben Ohev ShalomLos Robles Hospital & Medical Center SASARO AVEDIKIANLos Robles Hospital & Medical Center VWVictoria WatkinsLos Robles Hospital & Medical Center

Key Result

Temporary epicardial pacing served as a safe and effective bridging strategy for a patient with ESBL-producing E. coli tricuspid valve endocarditis complicated by advanced AV block.

Key Points

To report a rare case of infective endocarditis caused by ESBL-producing E. coli associated with advanced AV block.
Case presentation of a 75-year-old man with ESBL E. coli bacteremia and right bundle branch block.
Use of transthoracic and transesophageal echocardiography to diagnose tricuspid valve vegetation.
Emergency epicardial pacing was performed due to high-degree AV block and contraindications for transvenous pacing.
Tricuspid valve vegetation was identified on transesophageal echocardiography without abscess.
Progressive high-grade AV block necessitated urgent epicardial pacing due to active infection constraints.
Resolution of vegetation occurred after a six-week course of ertapenem, followed by successful transvenous pacemaker implantation.

Study Design

Type

Case Report (n=1)

Multicenter

Structured PICO

Population

A 75-year-old man with pre-existing right bundle branch block who developed progressive high-grade AV block secondary to ESBL-producing E. coli tricuspid valve infective endocarditis.

Intervention

6-week course of intravenous ertapenem and urgent epicardial pacing as a bridge to permanent transvenous dual-chamber pacemaker implantation.

Outcome

Resolution of tricuspid valve vegetation and successful implantation of a permanent transvenous pacemaker.

Epicardial pacing can serve as a safe bridging strategy for advanced AV block complicating active right-sided infective endocarditis when transvenous systems are contraindicated.

Limitations

Blood cultures were negative at presentation, likely due to prior ertapenem therapy.
The patient had pre-existing atrioventricular block, making it difficult to definitively prove causation between the infection and the progression to third-degree AV block.

Abstract

Abstract Background Infective endocarditis (IE) caused by non-HACEK gram-negative organisms accounts for fewer than 2% of cases, and endocarditis due to extended-spectrum β-lactamase (ESBL)–producing Escherichia coli is rare. Right-sided involvement, particularly isolated tricuspid valve infective endocarditis (TVIE), and associated atrioventricular (AV) conduction abnormalities are rarely reported, creating diagnostic and management challenges, especially when pacing is required. Case presentation A 75-year-old Caucasian man with pre-existing right bundle branch block presented with syncope one week after hospitalization for ESBL E. coli bacteremia treated with intravenous ertapenem. Electrocardiography now revealed progressive AV conduction delay with intermittent high-degree AV block. Transthoracic echocardiography was nondiagnostic, while transesophageal echocardiography identified a tricuspid valve vegetation without abscess despite antimicrobial therapy. Progressive high-grade AV block developed despite appropriate antimicrobial therapy, necessitated urgent epicardial pacing due to contraindication of transvenous systems in active infection. He completed a six-week course of ertapenem with subsequent resolution of the tricuspid valve vegetation on follow-up imaging. After infection clearance, a transvenous dual-chamber pacemaker was successfully implanted. Conclusions This case highlights an uncommon presentation of ESBL-producing E. coli TVIE complicated by advanced AV block. It underscores the importance of early transesophageal imaging in suspected right-sided endocarditis, awareness of conduction disturbances as a marker of disease severity, and the role of epicardial pacing as a safe bridging strategy when permanent transvenous systems are contraindicated during active infection.

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