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Infective endocarditis classically involves non-sterile vegetations on valvular surfaces in the heart. Feared complications include embolization and acute heart failure. Surgical intervention achieves source control and alleviates valvular regurgitation in complicated cases. Vegetations >1 cm are often intervened upon, making massive vegetations uncommon in modern practice. We report the case of a 39-year-old female with history of intravenous drug abuse who presented with a serpiginous vegetation on the native tricuspid valve and methicillin-resistant <i>Staphylococcus aureus</i> bacteremia. The vegetation grew to 5.6 cm by hospital day two, and she successfully underwent a tricuspid valvectomy. Six weeks of intravenous vancomycin therapy were completed without adverse events. To better characterize other dramatic presentations of infective endocarditis, we performed a systematic literature review and summarized all case reports involving ≥4 cm vegetations.