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Introduction:We present a case of a 65 year-old man with severe aortic regurgitation requiring a stented 23mm Edwards bioprosthetic aortic valve (BioAVR), who presented with 3-months of fevers and fatigue found to have Streptococcus gordonii(S. gordonii) infectious endocarditis (IE). He underwent dental cleaning 3-months prior sans prophylactic antibiotics. An echocardiogram on admission revealed increased peak/mean systolic gradients across the BioAVR to 46/26mmHg compared to gradients one year prior (32/19mmHg). Initially, a vegetation was not visualized by transthoracic echocardiogram (TTE) despite radiographic evidence of multi-organ emboli. Serial TTEs and transesophageal echocardiograms (TEEs) were performed due to persistent symptoms. Eventually, a new vegetation was visualized by TEE. A team effort involving cardiology, infectious disease, neurology, and cardiac surgery was required for management. Revision of the BioAVR was not pursued due to resolution of the vegetation. The patient was discharged after a prolonged hospitalization with recommendations to take amoxicillin 2g prior to future dental work.Results:Figure 1. A new 0.5cm vegetation visualized by TEE (A) with enlargement to 0.8cm (B), followed by a healed vegetation (C), and resolution 7-months later.Conclusions:S. gordoniihas historically been a rare cause of IE therefore requiring a high clinical suspicion for diagnosis. Approximately 8% of IE cases are caused by streptococci. However, a recent study in Denmark on streptococci IE implicated S. gordoniiin 44.2% of IE cases. S. gordoniiis a gram-positive cocci found in oral flora known to cause subacute bacterial endocarditis. Our case highlights the importance of detailed history-taking to identify sources of infection, serial multi-modal imaging evaluation despite initial negative findings particularly with persistent clinical symptoms, and a multidisciplinary approach to IE cases due to multi-organ involvement.

The authors capture the historical importance of the MANDELA trial and its unique study design, which examines two renal‐sparing strategies, not including a standard calcineurin inhibitor arm, after heart transplant to illustrate the ongoing challenge of balancing acute rejection and drug‐induced nephrotoxicity. See the original article from Barten et al on page 3006.