Complicated Prosthetic Valve Endocarditis Research Articles

Modified Commando procedure using a double valve composite through an aorto-annulo-septotomy.

Double valve replacement of aortic and mitral valves with intervalvular fibrous body reconstruction (Commando procedure) is a challenging operation. Particularly in redo surgery for prosthetic valve endocarditis, special techniques are needed for approaching and reconstructing the valve complex. We performed a modified Commando procedure using a double valve composite through an aorto-annulo-septotomy. This approach provided a good field of vision at the combined aortic and mitral annuli without incising the left atrial roof. The double valve composite with four-layer patch wings was useful for performing double valve replacement en bloc and aorto-annulo-septotomy closure serially. Using these techniques, we successfully performed the Commando procedure for complicated prosthetic valve endocarditis.

Salmonella Enteritidis ST11 Prosthetic Valve Endocarditis Complicated by a Paravalvular Abscess: Case Report and Literature Review

Salmonella infection typically causes self-limiting gastroenteritis. However, in rare cases, it can lead to prosthetic valve endocarditis (PVE), especially in older adults with a history of valve replacement surgery. In this case study, we describe a case of Salmonella PVE in a man with a prosthetic aortic valve. Complications of PVE include abscess formation, which is associated with increased mortality. If a patient with a history of prosthetic valve replacement presents with symptoms suggestive of gastroenteritis or bacteremia, a thorough investigation should be conducted with suspicion of PVE. The prognosis of Salmonella PVE can be improved by promptly initiating appropriate antibiotics and administering them for an adequate duration, as well as by considering surgical intervention when necessary. Additionally, confirming negative blood cultures after treatment of Salmonella bacteremia is important to prevent the development of PVE and paravalvular abscesses.

C55 A GIANT PSEUDOANEURYSM OF MITRAL–AORTIC INTERVALVULAR FIBROSA PRESENTING AS RECENT–ONSET ANGINA AND CARDIAC ARREST DUE TO VENTRICULAR FIBRILLATION

Abstract A 66–year–old man was suddenly referred to the emergency department (ED) for an extra–hospital cardiac arrest due to ventricular fibrillation, promptly treated by a single DC shock. Four months prior, he had undergone aortic valve replacement with a biological valve prosthesis (BVP, Perimount Magna n. 23) for severe aortic stenosis. One month after cardiac surgery the patient was hospitalized for acute cholecystitis requiring antibiotics and percutaneous cholecystostomy. On arrival to the ED the patient was awake and completely asymptomatic; no fever during days before the episode. He had been complaining of constricting retrosternal chest pain during physical exertion for ten days. However, no signs of ischemia were seen on the EKG. TT echo showed a very large pulsatile anaechogenic area posteriorly to BVP. Transesophageal echocardiography (TEE 2D, Traditional 3D and TrueVue) highlighted a very large pseudoaneurysm of mitral–aortic interventricular fibrosa (P–MAIVF; Figures 1 and 2, long axis and short–axis views). TEE features included: 1) a very large cavity with thickened walls, extended for more than two–thirds of the prosthetic circumference and with multiple septa; 2) a large communication between the left ventricular outflow tract (LVOT) and P–MAIVF (see yellow dotted line in Fig.1A) with a to–and–fro flow into the cavity and a prominent systolic pulsation; 3) no paraprosthetic leak and absence of any attached mass or intraprosthetic aortic regurgitation. These findings suggested a prosthetic aortic valve endocarditis with an extensive periannular involvement. Moreover, the P–MAIVF may have led to “ab extrinseco” compression of the left coronary artery, with a potential role in the genesis of chest pain and ventricular arrhythmia (in absence of significant CAD at preoperative coronary angiography). An empiric antibiotic therapy with daptomycin and piperacillin–tazobactam was started. The patients subsequently underwent Bentall surgery with a subannular implantation technique (Perimount valvular prosthesis n.23 and Gelweave vascular prosthesis n.28). Figure 3 shows an intraoperative image and postoperative TEE. In conclusion, P–MAIVF is an ominous complication of prosthetic valve endocarditis. Presentation with exertional angina and cardiac arrest is unusual. TEE is sensitive for diagnosis and 3D echo provides better insights into the anatomy helping formulate an appropriate surgical strategy.

An alternative approach for complicated prosthetic aortic valve endocarditis

BackgroundSurgical treatment of prosthetic valve endocarditis (PVE) with destruction of the aortic root and aortomitral continuity is demanding even in experienced hands.Case presentationHerein, we describe a case of a 71-year-old female patient who presented with PVE that was further complicated by a fistulous abscess cavity. The patient underwent removal of the dehisced prosthetic valve, radical annular debridement, reconstruction of the aortomitral curtain with a pericardial patch as a patch exclusion technique and implantation of a sutureless valve.ConclusionPatch exclusion technique, followed by sutureless valve implantation, might represent a feasible and safe alternative for the surgical treatment of complicated PVE.

A Case of Complicated Prosthetic Valve Endocarditis Successfully Managed Conservatively

Abstract Prosthetic valve endocarditis (PVE) is associated with high morbidity and carries a guarded overall prognosis. The management of this condition is based on consensus guidelines determined by various high-risk clinical and radiological features. Early surgery along with antibiotics has been the preferred option conventionally. We present a case of PVE with high-risk features that was successfully managed with antibiotics. This highlights the need for individualizing treatment based on prognostic evaluation rather than subjecting all patients to high-risk cardiac surgery.

ENTEROCOCCAL PROSTHETIC VALVE ENDOCARDITIS: A SILENT KILLER

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Prosthetic valve endocarditis (PVE) complicates 1-6% of all valve replacements and is associated with significant mortality (1). Compared to native valve endocarditis (NVE), PVE more commonly results in paravalvular abscess (1). Enterococcal endocarditis most commonly affects the elderly and those with prosthetic valves greater than 1 year old (2). CASE PRESENTATION: A 72 year-old male presented with 1 month of fever, myalgias and headache. Medical history included atrial fibrillation and mechanical aortic valve replacement in 2009. He was afebrile with a HR of 83 bpm, BP of 135/86mmHg, normal respiratory rate and SaO2 of 97% on room air. Cardiac exam revealed an irregularly irregular rhythm, a mechanical click and no murmurs. Neurologic exam showed disequilibrium. Lab results included a WBC count of 16,800/mm³, Hgb of 12.0 g/dL, INR of 3.16 and troponin of 1.32 ng/mL. Blood cultures were positive for Enterococcus faecalis. Transthoracic echocardiogram showed a 1.2x0.7cm mobile mass on the mechanical aortic valve without evidence of paravalvular complication. MRI brain showed cerebellar ischemia due to septic emboli. He was started on vancomycin and ceftriaxone. In an effort to rule out gastrointestinal (GI) malignancy or abscess, CT abdomen/pelvis was completed and normal. On hospital day 4, he had an 11-second pause requiring a transvenous pacemaker. On day 5, he went to the operating room for mechanical valve extraction and replacement and was found to have a subvalvular aortic abscess with a necrotic aortic root. He was unable to be weaned from cardiopulmonary bypass and died in the operating room. DISCUSSION: Enterococcal PVE is associated with increased risk of periprosthetic dehiscence and abscess (2). Studies have suggested that early surgical intervention should be considered in Enterococcal PVE due to the high likelihood of paravalvular complications (2,3). Echocardiography is less likely to detect paravalvular complications in PVE compared to NVE (3). Further data is needed to determine if GI lesions should be ruled out prior to intervention. Enterococcal PVE can have a subtle and subacute presentation but with catastrophic complications, such as seen in our case. These complications can be missed by echocardiography, resulting in delayed diagnosis and treatment. CONCLUSIONS: An early surgical approach should be considered for all patients with Enterococcal PVE. Paravalvular complications of PVE are often missed by echocardiography alone. Assessing for GI source of infection can delay intervention. Patients with prosthetic valves should be reminded that even minor symptoms can represent serious and life-threatening infection. Reference #1: Habib, G., et al. “Prosthetic Valve Endocarditis: Current Approach and Therapeutic Options.” Progress in Cardiovascular Diseases, vol. 50, no. 4, 2008, pp. 274–281. Reference #2: Chirouze, C., et al. “Enterococcal Endocarditis in the Beginning of the 21st Century: Analysis from the International Collaboration on Endocarditis-Prospective Cohort Study.” Clinical Microbiology and Infection, vol. 19, 2013, pp. 1140–1147. Reference #3: Nataloni, M., et al. “Prosthetic Valve Endocarditis.” Journal of Cardiovascular Medicine , vol. 11, 18 Dec. 2009, pp. 869–883. DISCLOSURES: No relevant relationships by Nayrana Griffith, source=Web Response No relevant relationships by James Lawrence, source=Web Response No relevant relationships by Patrick Miller, source=Web Response No relevant relationships by Andrew Stevens, source=Web Response

Incidence and outcome of prosthetic valve endocarditis after transcatheter aortic valve replacement in the Netherlands.

BackgroundTranscatheter aortic valve replacement (TAVR) is increasingly being used as an alternative to conventional surgical valve replacement. Prosthetic valve endocarditis (PVE) is a rare but feared complication after TAVR, with reported first-year incidences varying from 0.57 to 3.1%. This study was performed to gain insight into the incidence and outcome of PVE after TAVR in the Netherlands.MethodsA multicentre retrospective registry study was performed. All patients who underwent TAVR in the period 2010–2017 were screened for the diagnosis of infective endocarditis in the insurance database and checked for the presence of PVE before analysis of general characteristics, PVE parameters and outcome.ResultsA total of 3968 patients who underwent TAVR were screened for PVE. During a median follow-up of 33.5 months (interquartile range (IQR) 22.8–45.8), 16 patients suffered from PVE (0.4%), with a median time to onset of 177 days (IQR 67.8–721.3). First-year incidence was 0.24%, and the overall incidence rate was 0.14 events per 1000 person-years. Overall mortality during follow-up in our study was 31%, of which 25% occurred in hospital. All patients were treated conservatively with intravenous antibiotics alone, and none underwent a re-intervention. Other complications of PVE occurred in 5 patients (31%) and included aortic abscess (2), decompensated heart failure (2) and cerebral embolisation (1).ConclusionPVE in patients receiving TAVR is a relatively rare complication and has a high mortality rate.

Acute type A aortic dissection - a case beyond the guidelines

Introduction. There are not many cases among acute type-A aortic dissection survivors who get to be called ?incredible.? Here we present such a case followed-up for more than five years. Case outline. A 48-year-old male with acute type A aortic dissection, complicated with cardiac tamponade and severe aortic valve regurgitation, was submitted to emergent surgical treatment. Distal reconstruction was performed by complete aortic arch replacement with ?elephant trunk? extension and separate arch branch bypasses, while the proximal reconstruction was done with Bentall procedure. Total of 11 anastomoses was necessary to complete this procedure. Straight profound hypothermic (18o C) circulatory arrest, with a saturation of the venous blood from the jugular bulb of 97%, lasted 133 minutes. The patient was discharged stable without any neuro-cognitive deficit. Two years later, he was admitted with late prosthetic valve endocarditis and subvalvular abscess. Good response on treatment with efficient combined antibiotics and stabile hemodynamic allowed us to avoid barely feasible re-do surgery. Subvalvular myocardial abscesses evolved into periprosthetic pseudoaneurysms without infectious, thrombo-embolic, or hemodynamic deterioration. The patient is still alive and stable, more than four years after this event. Conclusion. Fortunate outcome of these life-threatening conditions is a reason to reconsider our understanding of cerebral function and metabolism during the profound hypothermic circulatory arrest, and it emphasizes the importance of measuring individual patient response against disease treatment guidelines, as we did, treating the late, complicated prosthetic valve endocarditis with medicaments, instead of high-risk surgery.

Rare cause of complicated prosthetic valve endocarditis

Rare cause of complicated prosthetic valve endocarditis

A complicated prosthetic valve endocarditis due to methicillin resistant Staphylococci treated with linezolid and ciprofloxacin: a case report

BackgroundProsthetic valve endocarditis (PVE) due to methicillin resistant Staphylococcus aureus (MRSA) is a rare disease with significant mortality and morbidity. With the emerging resistance and adverse effect profile of vancomycin which is the standard treatment, there is a compelling necessity of an effective alternative for vancomycin. Linezolid is proved as such an agent for infections caused by MRSA in other sites. However to-date the evidence for successful use of linezolid for MRSA prosthetic valve endocarditis is limited only for few case studies. We here present the third case reported as effective treatment of PVE by MRSA with linezolid and probably the first case reported with successful treatment with linezolid in a patient with multiple complications who is a candidate for surgery in standard guidelines.Case presentationA 45 years old male from Kandy Sri Lanka, who had undergone prosthetic valve replacement 10 years back, presented with prosthetic mitral valve endocarditis caused by MRSA. He failed to respond to vancomycin and cotrimoxazole while sustaining cerebral haemorrhages, as well as life threatening ventricular arrhythmias. Treatment with intravenous linezolid and ciprofloxacin resulted in a complete response with disappearance of the vegetations and sterilization of blood cultures.ConclusionsLinezolid can be considered as a good option for treating PVE by MRSA infections who are not responding to vancomycin and may negate the need for a surgery in patients awaiting an early surgery. Further studies including randomized controlled trials are needed to assess the efficacy of linezolid in PVE due to MRSA.

0163 : Prosthetic valve endocardites: still a serious complication

Prosthetic valve endocarditis (PVE) is still associated with significant mortality and morbidity despite progress in antibiotic therapy and cardiac surgery. The aim of this study is to describe clinical, characteristics, management and outcome of PVE. We conducteded a retrospective reviews of cases of certain infective endocarditis according to Duckes critera .among 135 patients hospitalized with infective endocarditis from 2004 to December 2014, 21 cases of PVE was found. Mean age of patients was ± 38.5 years (17 –79 years) with sex ratio=1.4. Mitral prosthesis was affected in 14 cases (67%) and aortic prosthesis in 7 cases (33%). Early prosthetic valve endocarditis was noted in 15 cases. Late PVE was observed in 5 patients; Mean interval of occurrencewas 150 days (extremes=8 days-2 year).Blood cultures were negatives in 55%. Staphylococcus aureus was the most common causative organism patients and occureded in 80%. Transthoracic and trans esophageal echocardiography revealed vegetations in all cases with mean size 14.4 mm (5-40 mm). Abscess was observed in 2 cases of aortic PVE. Desinsertion of prosthesis occurred in 6 patients. Mean duration of ant biotherapy was 20 days. Early surgery was indicated in 17 cases (80%). Essential complications consist in heart failure in 60%; stroke in 15% and cardiac abscess in 10cases.Hospital mortality was high estimated to 52.4%. Severals factor were associated to poor prognosis: age, staphylococal infection, early PVE and complicated PVE. PVE accounts for a high percentage of al l cases of infective endocarditis. Staphylococcus aureus is now the leading cause of PVE.High prevalence of negative blood cultures in our population is worring. Hospital mortality of PVE remains high despite prompt diagnosis and the frequent use of surgical intervention. The author hereby declares no conflict of interest

EComment. Early surgery for patients with uncomplicated prosthetic valve endocarditis

Attaran et al. [1] are to be commended for trying to answer an important question that recurrently arises in clinical practice: do all patients with prosthetic valve endocarditis (PVE) need surgery? The authors concluded after reviewing the relevant literature that redo surgery is warranted especially in case of complicated PVE, or when the culprit organism is Staphylococcus aureus. We entirely agree with their opinion and would like to add a brief comment concerning the timing of surgery in patients with uncomplicated PVE. Despite advances in medical and surgical care interventions, PVE remains a diagnostic and therapeutic challenge. PVE accounts for 10-30% of all cases of infective endocarditis [2], with the International Collaboration on Endocarditis, the largest registry of patients with endocarditis, reporting a PVE incidence of 20% [3]. Furthermore, the proportion of infective endocarditis cases undergoing surgery ranges from 28-42% as shown in a recent meta-analysis [4]. Unfortunately, PVE still carries a high mortality risk ranging from 20-80% of affected patients [2]. Therapeutic strategies for PVE are not backed by evidence-based recommendations. Although several retrospective studies showed that surgical intervention is indicated in cases of PVE with severe prosthetic dysfunction, heart failure, abscess formation and early staphylococcal infection, no randomized trials have been performed to examine the role of valve surgery in the management of PVE. There are no clear recommendations regarding the indication for surgery in PVE patients with uncomplicated large vegetations. Indeed, a recently published study tried to find an answer, albeit in patients with native valve endocarditis. The EASE study (Early Surgery versus Conventional Treatment in Infective Endocarditis) is a randomized control trial involving patients with native infective endocarditis, who were candidates for both early surgery and conventional treatment at two Korean medical centres [5]. They randomized 76 patients with vegetations larger than 10 mm, and severe valve dysfunction and assigned them to surgery within 48 hours after enrolment (early surgery) or to antibiotic therapy (conventional treatment). The primary end point was a composite of embolic events or death within 6 weeks after randomization. Early surgery prevented additional embolic events without increasing mortality, whereas 20% in the conventional treatment group had additional embolic events. Postponing the surgery in this patient population on the assumption that operating on them is too risky and challenging, exposes these patients to the hazard of further destruction of cardiac tissue as well as to the potential development of heart failure and embolic events, and might also render those patients ineligible for surgery due to complications of the disease or its treatment. Further randomized trials are warranted to refine the indications for and timing of surgery especially in patients with uncomplicated PVE. Conflict of interest: none declared

Do all patients with prosthetic valve endocarditis need surgery?

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was 'do all patients with prosthetic valve endocarditis need surgery?' Seventeen papers were found using the reported search that represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. These studies compared the outcome and survival between surgically and non-surgically treated patients with prosthetic valve endocarditis. Of these studies, two were prospective observational studies and the rest were retrospective studies. The results of most of these papers were in accordance with the guidelines of the American College of Cardiology and American Heart association. These studies showed that unless a patient is not a surgical candidate, an operation is the treatment of choice in prosthetic valve endocarditis. Surgery should be performed as soon as possible, particularly in haemodynamically unstable patients and those who develop complications such as heart failure, valvular dysfunction, regurgitation/obstruction, dehiscence and annular abscess. In addition to the above indications and cardiac/valvularrelated complications of prosthetic valve endocarditis, infection with Staphylococcus aureus plays an important role in the outcome, and the presence of this micro-organism should be considered an urgent surgical indication in the treatment of prosthetic valve endocarditis. Surgery should be performed before the development of any cerebral or other complications. In contrast, in stable patients with other micro-organisms, particularly those with organisms sensitive to antibiotic treatment who have no structural valvular damage or cardiac complications, surgery can be postponed. The option of surgical intervention can also be revisited if there is a change in response to the treatment. This option is reserved for selected patients only and we conclude that as soon as the diagnosis of prosthetic valve endocarditis is made, cardiac surgeons should be involved.

Usefulness of Three-Dimensional Transthoracic Echocardiography in Particular Clinical Settings: A Case of Aorto-Cavitary Fistula in Periprosthetic Aortic Valve Abscess

Prosthetic valve endocarditis (PVE) due to staphylococcus aureus is associated with high morbidity and mortality. Paravalvular abscess formation is a common complication of PVE at the aortic position, but fistula formation is rarely seen. The transesophageal echocardiography is the "gold-standard" exam to detect PVE. We present a case of a 69-year-old patient with prosthetic aortic valve endocarditis, paravalvular abscess, and fistula in right atrium, where the diagnosis was made with three-dimensional transthoracic echocardiography, without transesophageal evaluation.

Long-Term Survival of Salvage Cardiac Transplantation for Infective Endocarditis

Cardiac transplantation has been rarely performed in patients with infective endocarditis. A 31-year-old man developed aortic endocarditis due to Brucella melitensis. He presented with fever and developed acute myocardial infarct, severe aortic regurgitation, and heart failure. Aortic valve replacement did not improve cardiac function; hence, an emergent cardiac transplantation was carried out. Eighteen years later, he is doing well and living an active and productive life. Only 6 patients have received a cardiac transplant as part of the treatment of active infective endocarditis. This patient shows how cardiac transplantation may be successfully used as salvage therapy for patients with infective endocarditis who are not candidates for valve replacement or have severe and irreversible myocardial damage.

Treatment of prosthetic valve endocarditis complicated by destruction of the aortic annulus

It has been reported that surgical treatment for prosthetic valve endocarditis complicated by destruction of the aortic annulus is associated with high mortality and morbidity. The aim of this study was to evaluate the efficacy of our surgical strategy for this situation. Between October 2003 and April 2009, eight patients (mean age 68.6 years) with prosthetic valve endocarditis complicated by destruction of the aortic annulus were surgically treated at our hospital. We use a relatively simple procedure consisting of a patch plasty of the abscess cavity in addition to complete removal of the infected tissue of the abscess cavity followed by standard aortic valve replacement. All patients had active endocarditis and were in New York Heart Association functional class III or IV. Preoperative echocardiography revealed that four patients had moderate or severe aortic regurgitation, and two had mitral valve endocarditis as well. There were no operative deaths (≤30 days). Cardiac complications included paroxysmal atrial fibrillation in three patients and transient atrioventricular block in one. One patient died of multiple organ failure 66 days after the surgery. The overall in-hospital mortality was 12.5%. Patients were followed-up for 6-49 months (mean 31 months). There was no recurrent prosthetic valve endocarditis. One patient required reoperation (mitral annuloplasty and redo aortic valve replacement). There were two late deaths: lung cancer in one and multiple organ failure related to pneumonia after the aforementioned redo operation in the other. Our simple procedure for complicated prosthetic valve endocarditis yielded excellent early and midterm outcomes.

Actualización sobre endocarditis infecciosa en válvula protésica

Prosthetic valve endocarditis is still a matter of controversy especially the type of treatment that should be chosen for an individual patient. Since the current knowledge of this patology is based mainly on the literature and in its many and varied exponents (clinical experience, sistematic review, practice guideslines of cardiology associations, observational studies, etc), it is necessary to update the information continuously This review is focused mainly in the incidence, etiology diagnostics and treatment of prosthetic endocarditis. The principal microroganisms related to this patology are Staphylococcus aureus and coagulase-negative Staphyloccoco. Risk factors were identified for witch surgery is mandatory, such us Staphylococcus aureus infection and a complicated prosthetic valve endocarditis (cardiac failure, conduction abnormalities, abscess formation and recurrent embolism). With this information, patients that could have a medical treatment option can be recognized, as well as those who will require surgery. In order to present in a better way our conclusions, easily reading diagrams were included to facilitate the decision process when facing up a prosthetic valve endocarditis.

Embolizační komplikace protézové endokarditidy

Infekční endokarditida zůstává i v současné době závažným, život ohrožujícím onemocněním. Mortalita je vyšší u endokarditidy, která postihuje umělé chlopně, kdy přesahuje 30 %. Autoři představují případ protézové endokarditidy na náhradě aortální chlopně s embolizačními komplikacemi, které vedly ke zhoršení stavu a úmrtí pacienta.

Echocardiographic Evolution of Prosthetic Aortic Valve Endocarditis With Aorto-Left Atrial Fistula Formation

Prosthetic valve endocarditis (PVE) due to Staphylococcus aureus is associated with high morbidity and mortality. Paravalvular abscess formation is a common complication of PVE at the aortic position, but fistula formation is rarely seen. This report describes an 84-year-old patient with staphylococcal aortic PVE. Although paravalvular involvement was diagnosed early, clinical features associated with high operative mortality precluded surgical treatment. Unexpectedly, abscess drainage with aorto-left atrial fistula formation led to the remission of fever and clinical stabilization. Moreover, the echocardiographic evolution of infective endocarditis is described, from the initial lesion (vegetation) through abscess formation to partial valve dehiscence, abscess drainage, and aorto-left atrial fistula formation, by means of transesophageal echocardiography.

Aorta-atrial fistula, a rare complication of prosthetic valve endocarditis

A 51-year-old male with a history of a mechanical Carbomedics aortic and mitral valve replacement in 2003 and several re-operations because of endocarditis of the mitral valve in 2007 presented with heart failure 68 days after operation. Echocardiography confirmed the presence of a fistulous connection between the aorta and the left atrium. Because of the multiple surgical interventions and high operative risk, an initial conservative medical treatment was initiated and the clinical course was uneventful to this date.