MitraClip-related infective endocarditis in a frail, elderly patient: a case report

BACKGROUND: The incidence of infective endocarditis (IE) following a MitraClip is rare with 17 reported cases in the literature. The reported mortality rate is high, at 41%, despite both medical and surgical therapies. To date, this is the first documented case of IE following a MitraClip procedure in Australia. CASE SUMMARY: An 88-year-old male presented with a 1-week history of confusion and dyspnoea. Clinical examination was significant for a temperature of 37.7°C, a pansystolic murmur and bilateral pitting oedema to mid-shin, but no peripheral stigmata of IE. His history included a MitraClip procedure 11 weeks prior for severe mitral regurgitation. Initial blood cultures grew enterococcus faecalis. A transthoracic echocardiogram did not identify vegetations on the MitraClip. Subsequent transoesophageal echocardiogram (TOE) identified a 4 mm × 2 mm echodensity on the posterior mitral valve leaflet suggestive of IE. He was deemed not suitable for surgical intervention due to poor cognitive reserve and his medical comorbidities, so he commenced intravenous (IV) Ampicillin and Ceftriaxone which was later changed to Benzylpenicillin. Repeat TOE 2 weeks later showed the vegetation to have increased to ∼1 cm in length, so his treatment was reverted to Ampicillin. A further TOE 4 weeks later showed reduction in size to 5 mm × 2 mm. After 6 weeks of IV antibiotics, the patient was discharged on lifelong oral antibiotics. DISCUSSION: Infective endocarditis following MitraClip procedure is rare. This disease has a high mortality rate despite optimal medical and surgical therapy. Increased awareness amongst clinicians is important given an increasing volume of MitraClip procedures.