Early Mitral Valve Replacement in Infective Endocarditis Complicated by Ischemic Stroke with Hemorrhagic Transformation: A Case Report

Background: Infective endocarditis (IE) is a life-threatening condition associated with high morbidity and mortality, particularly when complicated by neurological events. Ischemic stroke occurs in up to 30% of IE cases and poses a major challenge regarding the timing of cardiac surgery due to the risk of hemorrhagic transformation. Case Presentation: We present the case of a 31-year-old Caucasian non-working female featuring progressive dyspnea, orthopnea, palpitations and retrosternal chest discomfort for the last two months. She had no cardiovascular or chronic medical disease before admission. One month prior, she developed sudden right-sided hemiparesis. Neuroimaging showed ischemic stroke with hemorrhagic transformation. Blood cultures grew Streptococcus viridans and transthoracic echocardiography showed a large, mobile vegetation (app. 13 mm) on the mitral valve. Due to high embolic risk, surgical treatment was undertaken following multidisciplinary decision with consideration by cardiology, neurology, neurosurgery, and cardiac surgery teams. After stabilization the patient required urgent mitral valve replacement with a mechanical prosthesis. Postoperatively, the patient was neurologically and hemodynamically intact, with no progression of hemorrhagic transformation. She received a 6-week course of targeted intravenous antibiotic therapy. At 3-month follow-up, she noted marked neurological recovery with motor strength up to approximately 4 out of 5 with independent ambulation and no cardiac complications. Conclusions: This case study suggests that early surgical management is safely available for several patients with ischemic and hemorrhagic transformation complications of IE only when considering carefully tailored patient multidisciplinary evaluation and close perioperative monitoring.