Hypothetical case: 50 year old male, previously well on no meds, presents with left parietal lobe intracerebral haemorrhage. Has fever and a murmur - echo shows large AV vegetation with positive blood cultures for diphtheroid organisms. There is free-flowing aortic regurgitation. He has a dense right sided hemiparesis which gradually improves over the next 3 weeks. Serial echo demonstrate an enlarging LV - LViDD 5.1 to 5.4 to 5.9cm over 3 weeks. Overall LV function remains good. Other heart valves normal on TEE.
His fever/CRP respond well to conventional IV antibiotic therapy.
Clearly the patient needs aortic valve replacement. Likely he had an embolic event from his AV that induced haemorrhage in his brain. My question is how long to delay AVR? There is a risk of his LV dilating more, but also the risk of bleeding into his brain when he is placed on bypass and fully heparinised.
Any comments?