Article Details

Background: Isolated pulmonary valve endocarditis (PVE) is an uncommon form of infective endocarditis, accounting for less than 2% of cases. It most commonly occurs in patients with intravenous drug use, congenital heart disease, indwelling catheters, or prosthetic material. Its infrequency, coupled with nonspecific clinical features and the absence of dedicated management guidelines, renders diagnosis and treatment particularly challenging.
Case Presentation: We describe a 63-year-old male without traditional risk factors who presented with malaise and persistent Enterococcus faecalis bacteremia following a complicated urinary tract infection associated with nephrolithiasis and ureteral stenting. Despite appropriate antimicrobial therapy, blood cultures remained positive. Transesophageal echocardiography revealed a large, mobile mass on the pulmonary valve with moderate-to-severe pulmonary regurgitation, raising concern for endocarditis versus a cardiac tumor.
Diagnosis and Management: The patient was diagnosed with isolated PVE complicated by refractory bacteremia. Given failure of medical therapy and evidence of valvular destruction, he underwent surgical pulmonary valvectomy with concomitant coronary artery bypass grafting. Definitive pulmonary valve replacement was deferred until bloodstream sterilization was achieved, necessitating a staged surgical approach with temporary mechanical circulatory support for multifactorial shock.
Outcomes: Histopathology confirmed infective endocarditis with extensive valve destruction and E. faecalis infiltration. Following stabilization and delayed bioprosthetic pulmonary valve replacement, the patient recovered and was discharged to rehabilitation where he completed a 6-week postoperative course of ampicillin and ceftriaxone. 
Conclusions: This case highlights the diagnostic complexity and multidisciplinary management required for isolated PVE and emphasizes the importance of considering endocarditis in patients with persistent bacteremia, even in the absence of classic risk factors.

Keywords: Pulmonary valve endocarditis; Valve replacement; Shock; VA-ECMO; CABG