Ruptured Root Abscess with Aortopulmonary Fistula Caused by Vancomycin-Resistant-Enterococcus Prosthetic Valve Endocarditis.

Vancomycin-Resistant-Enterococcus (VRE) prosthetic valve endocarditis leading to a ruptured aortic root abscess and an aortopulmonary fistula is rare. A 77-year-old woman with recent VRE prosthetic valve (TAVR) endocarditis being treated with ampicillin and daptomycin for two weeks presented with bradycardia and hypotension in the setting of marked hypokalemia. Her hospital course was complicated by acute kidney injury. On day two of her hospitalization, she developed expressive aphasia, and an MRI was performed, which showed a corona radiata stroke. A transesophageal echocardiogram was pursued to assess for an embolic cause of her stroke. The echocardiogram showed a ruptured root abscess with an aortopulmonary fistula. After a risk and benefits discussion, the patient elected to pursue medical management. She was considered a high-risk surgical candidate in light of her recent stroke and worsened renal function. Moreover, her quality-of-life goals did not align with a prolonged or aggressive treatment approach. Optimal management strategies for patients with prosthetic valve infective endocarditis complicated by multiple comorbidities have not been elucidated. Treatment options require a careful balance of risks and benefits. Clinicians must astutely tailor recommendations to each patient based on their comorbidities.