Prosthetic Mitral Valve Endocarditis Presenting as Complete Heart Block

A 60-year-old male patient with a prior history of diabetes mellitus type II, hypertension, and mitral valve replacement with mechanical prosthesis in 2012 on warfarin presented to the hospital with lethargy, nausea, vomiting, and intermittent fevers for 2 weeks. The patient was appropriately treated for a urinary tract infection with 2 rounds of antibiotics in the last 2 weeks prior to presentation. The patient also complained of mild blurriness of vision in both eyes. His blood pressure was 110/70 mmHg, and his heart rate was 48 bpm with normal oxygen saturation at room air. He was febrile to 102°C and was oriented to person, place, and time but exhibited minimal confusion. His exam was significant for a mechanical click on cardiac auscultation. The patient did not exhibit any significant abnormalities on physical examination, and there was no evidence of focal deficits. Figure 1 shows his electrocardiogram at presentation. Computed tomography (CT) scan of the brain was suspicious for a very small right subarachnoid hemorrhage. His international normalized ratio (INR) level was elevated at 9 on laboratory testing.

Figure 1

Figure 1
The electrocardiogram demonstrated atrioventricular (AV) dissociation and complete heart block.

Which of the following is the next best step in management?

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