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A 36-year-old woman is evaluated in the emergency department for fever and dyspnea. She reports a 4-week history of recurrent fevers as high as 40 °C (104 °F). She has had intermittent night sweats and decreased appetite. She admits to recreational drug use with heroin; her last use was 3 days ago.
Her temperature is 39.6 °C (103.2 °F), heart rate is 70/min, blood pressure is 100/52 mm Hg, and oxygen saturation is 91% on room air. She appears agitated and uncomfortable. Her jugular venous pressure is estimated at 12 cm H2O. She has bibasilar crackles on lung auscultation. Her heart rate is regularly irregular. Auscultation reveals a soft S1 with a prominent but muffled S2. An S3 and S4 are not present. A grade 2/6 diastolic murmur is heard loudest at the right 2nd intercostal space. She has 1+ bilateral pedal edema.
Laboratory evaluation includes a hematocrit of 34% and a leukocyte count of 18,000/μL (18 × 109/L) with a left shift. Serum creatinine is 2.4 mg/dL (212.21 μmol/L). The rest of the laboratory evaluation is unremarkable.
The electrocardiogram is shown (;" name=tip tip="[img>'../figures/thumbs/mk14_a_cv_mcq_f019.jpg'/[/img]] Figure 19). Transesophageal echocardiography demonstrates normal left ventricular size with hyperdynamic systolic function. There are two 0.8-cm vegetations on the aortic valve, with valve leaflet perforation and severe aortic regurgitation. There is an echolucency in the paravalvular region. No abnormalities are seen on the other cardiac valves. Blood cultures are drawn and empiric broad-spectrum antibiotics are started.
Which is the most appropriate treatment at this time?
A Esmolol intravenously B Heparin intravenously C Intra-aortic balloon pump D Permanent pacemaker placement E Aortic valve replacement This question has been answered. To clear answers, open the Answer Sheet. Answer and Critique (Correct Answer = E)
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