How do you approach mitral valve endocarditis associated with a large vegetation size and severe mitral regurgitation, but without any heart failure, hemodynamic instability or valve destruction?

This is a great question and it poses the risk-benefit of the situation nicely. This stems off the 2012 NEJM (Kang et al., PMID 22738096) paper linked in the question, comparing Early (<48 hr) vs Conventional/Abx treatment for large vegetation (>10 mm) without major stroke yet. Summary: this was pre...

In case of large valvular vegetations with the potential for valvular destruction and abscess formation, early intervention is recommended based on the size of the valvular vegetation.

In spite of the fact that the patient does not have congestive heart failure in the setting of severe mitral regurg...

It is important to get CVS involved early and to work with ID to coordinate antibiotics pre-op. We have sometimes given a week or two of antibiotics to prep the patient for definitive treatment with surgery but the risks of stroke, heart block, or hemodynamic collapse are real. I usually tell the pa...