Late Prosthetic Valve Endocarditis Research Articles

Beyond the Timeline: One-year Mortality Trends in Early vs. Late Prosthetic Valve Endocarditis.

Among 302 episodes with prosthetic valve endocarditis (PVE), one-year mortality was 31%. There was no evidence indicating that early-onset PVE within 6 months from valve surgery led to a worse outcome compared to late-onset PVE (21% versus 32%; p=0.126), despite similar redo valve surgeries across both categories.

Treatment of Late Infective Prosthetic Endocarditis Complicated by Cerebral Infarction with Vegetations: Pharmacotherapeutic Approach (Case Report)

Prosthetic endocarditis is a serious complication in a long term. Vegetation as a thromboembolic complication leads to neurologic deficit varying in severity.
 Case description. A 35-year-old female patient F. underwent surgical treatment at the Department of Surgical Treatment of Acquired Heart Diseases of the National Amosov Institute of Cardiovascular Surgery on September 07, 2016: aortic valve replacement with wrapping tape operation II. The patient was discharged from the hospital on the 9th day after surgery in a satisfactory condition. On November 20, 2019, the patient was admitted to the Institute with the diagnosis of late infective prosthetic aortic valve endocarditis, status post aortic valve replacement and wrapping tape operation in 2016, first-degree atrioventricular block, cerebral infarctions in multiple locations with hemorrhagic transformation, with aphasia elements, ataxia, right-sided pyramidal insufficiency and suspected meningitis. After 21 days of drug therapy, the patient responded to treatment successfully and was discharged from the hospital in a satisfactory condition without surgical treatment.
 Conclusions. Taking into consideration the serious condition of the patient, timely and carefully selected drug therapy can be the correct solution for the treatment of patients with late infective endocarditis. Thus, surgery is not always the treatment of choice.

Management of infectious endocarditis from the perspective of the Infectious Diseases specialist – a 2023 update

An increase in the number and the complexity of cardiac surgery has brought on a rise in the proportion of healthcare-associated Infectious Endocarditis (IE), and as a result, today S. aureus is the most common causative pathogen for this condition. Clinical suspicion for IE should be raised in front of a patient with predisposing risk factors, a new heart murmur and/or vasculitic/embolic events. The Duke Criteria have been long used to diagnose IE. However, they underwent several changes in order to improve their sensitivity in the diagnosis of Q-fever IE and to decrease the size of the possible IE group. Our primary goal is to enhance the knowledge regarding the diagnosis and treatment of infective endocarditis. In acute IE, prior to beginning antibiotic therapy, at least three sets of blood cultures must be taken, ideally from three distinct sites, as determining the etiologic agent is of highest importance. The diagnosis of IE cannot be made based just on a single positive blood culture. To diagnose subacute IE, three to five sets of blood cultures must be drawn over the course of 24 hours. Transthoracic echocardiography (TTE) remains the preferred investigation when the diagnosis of IE is suspected. Transesophageal echocardiography (TOE) is recommended when TTE is unremarkable but the suspicion is still high. A whole-body CT scan, an MRI, a cardiac CT, PET-CT, or radiolabeled leucocyte single-photon emission computed tomography may be helpful when TTE and TOE are inconclusive. Recommended empirical therapy for Native Valve Endocarditis (NVE) and late Prosthetic Valve Endocarditis (PVE) consists of IV Amoxicillin, Oxacillin and Gentamicin administered until blood culture results are available. If a patient is allergic to penicillin, IV Vancomycin and Gentamicin should be given. The recommended empirical antibiotic regimen for early PVE includes IV Vancomycin, Gentamicin, and Rifampin. Once the results of blood cultures are available, the treatment will depend on the isolated organism, its sensitivity to antibiotics, and whether it is an NVE or a PVE.

Prosthetic valve endocarditis after transcatheter aortic valve replacement in low-risk patients.

We sought to report details of the incidence, organisms, clinical course, and outcomes of prosthetic valve endocarditis (PVE) after transcatheter aortic valve replacement (TAVR) in low-risk patients. PVE remains a rare but devastating complication of aortic valve replacement. Data regarding PVE after TAVR in low-risk patients are lacking. We performed a detailed review of all patients in the low-risk TAVR trials who underwent TAVR from 2016 to 2020 and were adjudicated to have definitive PVE by the independent Clinical Events Committee. We analyzed 396 low-risk patients who underwent TAVR (including 72 with bicuspid valves). PVE occurred in 11 patients at a median 379 days (210, 528) from TAVR. The incidence within the first 30 days was 0%; days 31-365, 1.5%; and after day 365, 2.8%. The most common organism identified was Streptococcus (n=4/11). Early PVE (≤ 365 days) occurred in five patients, of whom three demonstrated evidence of embolic stroke and two underwent surgical aortic valve re-intervention. Late PVE (> 365 days) occurred in six patients, of whom thee demonstrated evidence of embolic stroke and only one underwent surgical aortic valve re-intervention. Of the six patients with evidence of embolic stroke, two died, two were discharged to rehabilitation, and two were discharged home with home care. PVE was infrequent following TAVR in low-risk patients but was associated with substantial morbidity and mortality. Embolic stroke complicated the majority of PVE cases, contributing to worse outcomes in these patients. Efforts must be undertaken to minimize PVE in TAVR.

MIGHTY MITIS

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Transcatheter Aortic Valve Replacement (TAVR) is the mainstay treatment of severe aortic stenosis especially in the elderly with multiple comorbidities and is emerging as an alternative to surgical aortic valve replacement (SAVR). (1) The rate of infective endocarditis (IE) following TAVR has been reported to be around 1.5%.(2) Herein, we describe a case where the patient developed prosthetic valve endocarditis (PVE) 2 months after undergoing TAVR. CASE PRESENTATION: A 73-year-old male presented to the emergency with cough, chills, and bilateral lower extremity swelling for a week. His medical history was significant for hypertension, hyperlipidemia, type 2 diabetes mellitus, bradycardia status post dual lead pacemaker (2013), and severe aortic stenosis status post TAVR (26mm SAPIEN 3 valve via right femoral artery- TAVR was done 2 months prior to this presentation). The patient underwent a dental procedure 3 weeks after the TAVR and did not receive any antibiotic prophylaxis prior to the dental procedure. Duke Criteria indicated ‘Possible infective endocarditis (IE)’. Transthoracic echocardiogram (TTE) did not show any vegetation. Blood cultures yielded Streptococcus mitis/ oralis. Transesophageal echocardiogram (TEE) showed 0.6 X 0.2cm vegetation on the left coronary cusp of the prosthetic aortic valve and mild paravalvular aortic insufficiency. The pacemaker was vegetation-free. He was started on intravenous (IV) ceftriaxone, responded well to it, and was discharged with a 6weeks course of IV ceftriaxone and he was referred to cardiothoracic surgery for further evaluation. DISCUSSION: IE is an uncommon complication after TAVR. PVE associated with TAVR is difficult to diagnose and has a dismal prognosis so TAVR- IE deserves prompt diagnosis and treatment. PVE presents with fever, new or changing heart murmur, new or worsening heart failure, or new or progressive cardiac conduction abnormalities. The most frequently encountered pathogens in early PVE (within two months of TAVR) are S. aureus and coagulase-negative staphylococci followed by gram-negative bacilli and fungi. The most frequently encountered pathogens in intermediate PVE (2 to 12 months after TAVR) and late PVE (more than 12 months after TAVR) are streptococci and S. aureus followed by coagulase-negative staphylococci and enterococci. The main sources of PVE are dental interventions and respiratory, skin, urological, and gastrointestinal infections.(2) Studies have shown that men are found to be affected by IE more often than women. (3) CONCLUSIONS: As per the American Heart Association (AHA) and the European Society for Cardiology (ESC) guidelines, PVE should be treated with a bactericidal agent for at least six weeks. Guidelines recommend early surgery in complicated cases including those with heart failure, perivalvular complications, and high risk of embolism. Emphasis should also be given on any pre-procedure prophylaxis. Reference #1: Smith CR, Leon MB, Mack MJ, Miller DC, Moses JW, Svensson LG, Tuzcu EM, Webb JG, PARTNER Trial Investigators. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med. 2011;364:2187–98. Reference #2: Amat-Santos IJ, Ribeiro HB, Urena M, Allende R, Houde C, Bédard E, Perron J, Delarochellière R, Paradis JM, Dumont E, Doyle D, Mohammadi S, Côté M, San Roman JA, Rodés-Cabau J. Prosthetic valve endocarditis after transcatheter valve replacement: A systematic review. JACC Cardiovasc Interv. 2015;8:334–346. Reference #3: Olsen NT, Backer O De, Thyregod HGH, Vejlstrup N, Bundgaard H, Søndergaard L. Structural Heart Disease Prosthetic Valve Endocarditis After Transcatheter Aortic Valve Implantation. 2015;1–9. DISCLOSURES: No relevant relationships by Sanya Chandna, source=Web Response No relevant relationships by Kesavan Sankaramangalam, source=Web Response No relevant relationships by Monarch Shah, source=Web Response

Trifecta Versus Perimount Magna Ease Aortic Valve Prostheses

Recent surgical bovine pericardial prostheses are widely used despite limited data on their long-term durability. This is a comparative analysis of the outcome of the Trifecta (Abbott, Abbott Park, IL) and Perimount Magna Ease (Edwards, Lifesciences Corp, Irvine, CA) bioprostheses from the FinnValve registry, a Finnish nationwide database including patients with aortic stenosis who underwent transcatheter or surgical aortic valve replacement with a bioprosthesis between 2008 and2017. Overall 2216 patients (mean age, 74.1 ± 6.7 years; age <65 years, 8.9%; mean follow-up, 3.8 ± 2.1 years) received the Trifecta (851 patients) or the Perimount Magna Ease (1365 patients) bioprostheses. The rates of late mortality and prosthetic valve endocarditis were comparable in the study cohorts. At 7 years the Trifecta cohort had a significantly higher risk of repeat aortic valve replacement for structural valve failure (3.3% vs 0%; adjusted subdistribution hazard ratio, 2.224; 95% confidence interval, 1.044-4.737), repeat aortic valve replacement for any cause (3.6% vs 0.4%; adjusted subdistribution hazard ratio, 3.210; 95% confidence interval, 1.286-8.013), and repeat aortic valve replacement and/or prosthetic valve endocarditis (4.1% vs 0.9%; adjusted subdistribution hazard ratio, 3.210; 95% confidence interval, 1.286-8.013) compared with the Perimount Magna Ease cohort. Among 772 propensity score-matched pairs, at 7 years the Trifecta cohort had a higher risk of repeat aortic valve replacement for structural valve failure (5.7% vs 0%, P= .009). The Trifecta aortic bioprosthesis is associated with a higher occurrence of repeat aortic valve replacement for structural valve failure compared with the Perimount Magna Ease bioprosthesis. Further comparative studies with echocardiographic data on structural valve deterioration and longer follow-up are needed to confirm these findings.

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.

Valve-related factors and incidence of prosthetic valve endocarditis.

AimThe aim of the study was to present our experience and evaluate the valve-related factors and the incidence of prosthetic valve endocarditis.Material and methodsThis is a retrospective study. Between 2010 and 2018, 36 patients were re-operated on due to prosthetic valve endocarditis The valve-related factors (type, size and position of the prosthetic valve) were analysed.ResultsThirty-six patients had prosthetic valve endocarditis. The overall hospital mortality was 16.67%. Early vs. late onset prosthetic valve endocarditis mortality was 23.08% vs. 13.04% respectively. The type, size or position of the prosthesis was not associated with prosthetic valve endocarditis. There was a statistically significant difference between occurrence of prosthetic infection between mitral repair and replacement both in mechanical and biological valve groups. The most common infective agent in the early onset group was Staphylococcus aureus, whereas in the late onset group it was Enterococcus faecalis. Out of 13 patients with early prosthetic valve endocarditis, 11 had infection in the perioperative period around primary operation.ConclusionsBased on our experience, prosthetic valve endocarditis has a high mortality. Early onset prosthetic valve endocarditis is less common but has higher mortality compared to the late onset. Mitral valve repair was less prone to develop prosthetic valve endocarditis, and valve-related factors (type and size of the valve, valve position) did not have any influence on the incidence of prosthetic valve endocarditis.

Infective endocarditis after transcatheter aortic valve implantation: a nationwide study.

Aims Transcatheter aortic valve implantation (TAVI), now a common procedure to treat high-risk patients with severe aortic stenosis, has rapidly been expanding into younger and lower-risk populations, creating a need to better understand long-term outcome after TAVI. The aim of the present investigation was to determine the incidence, risk factors for, clinical presentation of, and outcome after prosthetic valve endocarditis (PVE) in patients treated with TAVI in a nationwide study.Methods and results Three registries were used: a national TAVI registry, a national diagnosis registry, and a national infective endocarditis registry. Combining these registries made it possible to perform a nationwide, all-comers study with independent and validated reporting of PVE in 4336 patients between 2008 and mid-2018. The risk for PVE after TAVI was 1.4% (95% confidence interval 1.0–1.8%) the first year and 0.8% (0.6–1.1%) per year thereafter. One-year survival after PVE diagnosis was 58% (49–68%), and 5-year survival was 29% (17–41%). Body surface area, estimated glomerular filtration rate <30 mL/min/1.73 m2, critical pre-operative state, mean pre-procedural valve gradient, amount of contrast dye used, transapical access, and atrial fibrillation were identified as independent risk factors for PVE. Staphylococcus aureus was more common in early (<1 year) PVE. Infection with S. aureus, root abscess, late PVE, and non-community acquisition was associated with higher 6-month mortality.Conclusion The incidence of PVE was similar to that of surgical bioprostheses. Compromised renal function was a strong risk factor for developing PVE. In the context of PVE, TAVI seems to be a safe option for patients.Clinical Trial RegistrationNCT03768180 (http://clinicaltrials.gov/).

Late prosthetic valve endocarditis with Mycobacterium tuberculosis after the Bentall procedure

BackgroundProsthetic valve endocarditis (PVE) is a rare but severe complication of valve replacement surgery, with an incidence rate of 0.3–1.2% per patient-year. At present, staphylococci are the predominant causative microorganism of PVE. Herein, we report a confirmed case of late PVE in a mechanical aortic valve caused by Mycobacterium tuberculosis.Case presentationA 32-year-old immunocompetent man with recurrent fever and 5-kg weight loss had a history of having undergone the Bentall procedure due to congenital heart disease. Nine years after the operation, he developed a paravalvular abscess in the mechanical aortic valve, presented with evidence of pulmonary tuberculosis on CT scan and was diagnosed with tuberculous endocarditis. This case report highlights a rare and non-negligible example of tuberculous endocarditis involving a mechanical valve.ConclusionsTuberculous PVE should be considered in patients with a history of valve replacement, recurrent fever, unexplained weight loss, pulmonary tuberculosis and meaningful valvular findings on echocardiogram.

Surgical outcomes of mitral valve replacement with concomitant mitral annular reconstruction.

We evaluated the early and long-term outcomes of mitral annular reconstruction (MAR) with pericardium during mitral valve replacement (MVR), and analyzed the risk factors associated with post-operative mortality. Between May 1997 and April 2013, 78 consecutive patients underwent MVR with MAR. The indications for MAR were treatment for annular infection in native valve endocarditis (n = 23, 29.5%) or prosthetic valve endocarditis (n = 26, 33.3%), reinforcement of damaged annulus resulting from a previous operation (n = 17, 21.8%), complete excision of extensive calcification (n = 9, 11.5%), and left ventricular or left atrial rupture (n = 3, 3.8%). Patients were classified into infective endocarditis (n = 49) and non-endocarditis groups (n = 29). The mean follow-up period was 59.4 ± 47.3 months. There were two operative deaths and 11 cases of late mortality in the endocarditis group and five cases in the non-endocarditis group. Late prosthetic valve endocarditis occurred in four patients. The overall survival rate at 1 and 10 years was 94.8% and 65.1%, respectively. There was no statistical difference in the overall survival, freedom from reoperation, and freedom from endocarditis rates between the groups (P = 0.565, P = 0.635, and P = 0.449, respectively). Univariable and multivariable analyses revealed that pre-operative left ventricular dysfunction (ejection fraction <40%) was an independent predictor of overall mortality. The early and long-term results of MAR with pericardium during MVR are acceptable in both endocarditis and non-endocarditis patients.

Late Prosthetic Valve Endocarditis - Clinical Fate and Further Outcome

Late Prosthetic Valve Endocarditis - Clinical Fate and Further Outcome

Recurrent Late Prosthetic Valve Endocarditis and Operative Discovery of a Peri-Annular Abscess–A Case Report

Recurrent Late Prosthetic Valve Endocarditis and Operative Discovery of a Peri-Annular Abscess–A Case Report

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

Surgical treatment of late aortic prosthetic valve endocarditis: 19 years' experience.

Aim of the studyWe retrospectively analyzed the results of operations conducted for aortic prosthetic valve endocarditis in a single center over 19 years.Material and methodsFrom February 1992 to January 2011, we performed operations on 27 patients with aortic prosthetic valve endocarditis. Seventeen patients (63.0%) were male, and the mean age was 39.1 ± 14.2 (16-67) years. Blood cultures were positive in 11 patients (40.7%), and the most commonly identified microorganism was Streptococcus (7 patients, 25.9%). The mean duration of follow-up was 8.6 ± 4.7 years (0.5-18.2), adding up to a total of 136.9 patient/years.ResultsForty procedures were performed on these 27 patients. The most commonly performed procedure was aortic valve replacement with a prosthetic valve – 16 patients (59.3%). Fifteen patients were operated on during the active phase of infection. In-hospital mortality was observed in 11 patients (40.7%). Postoperatively, 12 patients (44.4%) had low cardiac output, 3 (11.1%) suffered from a heart block; none of them required permanent pacemaker implantation. The actuarial survival for 1 and 5 years was 55.6 ± 9.6% and 47.6 ± 9.7%, respectively.ConclusionsProsthetic valve endocarditis of the aortic valve is a challenging situation for the surgeon. The surgical treatment carries a high mortality rate and long-term survival is low. Among the survivors, however, recurrence and the need for reoperation are unlikely.

Cytokine profiles linked to fatal outcome in infective prosthetic valve endocarditis

Infective endocarditis is a disease normally of bacterial cause which affects the endocardic tissue, specifically the valves (native or prosthetic). It is a serious illness and mortality rates remain high, ranging between 20% and 40%. Previous reports have evidenced the potential role of cytokines in the diagnosis of this disease, but no information is available on their relationship with outcome. We recruited 26 consecutive patients with late prosthetic valve endocarditis requiring surgical treatment according to Duke criteria. Eight cytokines were measured in plasma in the first 24 h following diagnosis by using a Bio-Rad multiplex assay. Levels of IL-6, IL-8 and interferon gamma (IFN-γ) were higher in non survivors. Receiver operating characteristic curve analysis evidenced that IL-6, IL-8 and IFN-γ behaved as good diagnostic tests for identifying those patients with fatal outcome (area under the curve, CI 95%, p): IL-6: [0.81 (0.61-1.00) 0.012]; IL-8 [0.76 (0.56-0.96) 0.035]; IFN-γ [0.79 (0.59-0.99) 0.021]. Levels of IL-6, IL-8 and IFN-γ correlated positively between them, indicating that they are produced as consequence of a simultaneous response to the infection. Our findings support the participation of IL-6, IL-8 and IFN-γ in the events linked to fatal outcome in infective prosthetic valve endocarditis.

Recurrent Prosthetic Mitral Valve Dehiscence due to Infective Endocarditis: Discussion of Possible Causes

Prosthetic valves are being widely used in the treatment of heart valve disease. Prosthetic valve endocarditis (PVE) is one of the most catastrophic complications seen in these patients. In particular, prosthetic valve dehiscence can lead to acute decompensation, pulmonary edema, and cardiogenic shock. Here, we discuss the medical management of late PVE in a patient with a prior history of late and redo early PVE and recurrent dehiscence. According to the present case, we can summarize the learning points as follows. A prior history of infective endocarditis increases the risk of relapse or recurrence, and these patients should be evaluated very cautiously to prevent late complications. Adequate debridement of infected material is of paramount importance to prevent relapse. A history of dehiscence is associated with increased risk of relapse and recurrent dehiscence.

Molecular evidence of Enterococcus faecalis in an occluding coronary thrombus from a patient with late prosthetic valve endocarditis

Molecular evidence of Enterococcus faecalis in an occluding coronary thrombus from a patient with late prosthetic valve endocarditis

Surgical treatment for active infective prosthetic valve endocarditis: 22-year single-centre experience☆

We retrospectively analysed the profile and outcome of surgically treated patients with active infective prosthetic valve endocarditis (PVE) over a period of 22 years. Between May 1986 and December 2008, a total of 1313 patients with active infective endocarditis (AIE) were operated on, 349 (26.6%) of them for PVE. Of these, 77 (22.1%) had to be operated upon due to early PVE (≤60 days, n=55 men, median age: 58 years) and 272 (77.9%) due to late PVE (n=200 men, median age: 63 years). A large proportion of patients were referred to our department with advanced endocarditis and in a condition of cardiac and pulmonary decompensation. A total of 226 (64.8%) patients developed periannular abscess. Operations consisted of 80 aortic valve, 45 mitral valve, 39 double valve and 165 aortic root replacements, 134 of them with a homograft. Perioperative characteristics, probability of survival, freedom from recurrence and predictors for hospital mortality were analysed. Follow-up (maximum: 19.4 years) was completed in 96.3% (total: 1118 patient-years). There was high early and late mortality. Overall in-hospital mortality was 28.4% (99/349). The 30-day, 1-, 5- and 10-year survival for the whole PVE study population was 71.4 ± 2.4%, 58.7 ± 2.7%, 44.5 ± 3% and 31.7 ± 3.5% with no significant differences between the early and late PVE patients: 67 ± 5.4%, 55.9 ± 5.8%, 49.4 ± 6.2% and 29.7 ± 7.6%, compared to 72.4 ± 3%, 60 ± 3%, 43.5 ± 3.3% and 31.1 ± 3.8% (p=0.93). Predictors of early mortality were mechanical support (risk ratio (RR): 4.3), emergency operation (RR: 2.1), preoperative high doses of catecholamines (RR: 1.8), mitral valve replacement (RR: 1.5) and age at operation (RR: 1.1). Freedom from re-operation due to recurrent endocarditis at 10 years was 85.8 ± 5.6% for early PVE compared to 92.1 ± 2.3% for late PVE patients (p=0.17). Staphylococcus aureus (S. aureus) (18.1%) was the most frequent causative micro-organism. Surgery for active infective PVE continues to be challenging. It not only carries a high in-hospital mortality but is also associated with a high long-term mortality risk. Early PVE patients were in a more severe condition than late PVE patients. Preoperative status, complications and co-morbidity of PVE patients strongly predict early outcome. Because of the potential risk of late complications, PVE patients need close clinical follow-up.

179 Clinical and echocardiographic predictors of mortality in prosthetic valve endocarditis

Prosthetic valve endocarditis (PVE) is a rare and serious complication after heart valve replacement. Despite progress in therapeutic modalities, morbidity and mortality remain untolerably high. To evaluate the current outcome of PVE in a high volume tertiary care center in Tunisia and to analyse predictors of mortality. All cases of PVE treated in our institution between 1997 and 2008 were analysed according to the modified DUKE criteria. Univariate and multivariate analysis were performed to assess predictors of mortality. Two sided p values<0.05 were considered significant. During the study period, 234 IE were diagnosed, among them 74 were PVE (42 males and 32 females), mean age was 39.23 years. They were early PVE in 38 cases (51.4%) and late PVE in 36 cases (48.6%). 28 patients (38.7%) underwent surgical intervention during the active phase. 14 patients died during index hospitalization (i.e. 18.9% in hospital mortality). In comparison with survivors, patients who died had a considerably longer delay to diagnosis (18.9 days vs 8.89; p=0.03), more hyperleucocytosis (14678 vs 10234; p=0.015) and more severe anemia (8.56 g/dl vs 10.46g/dl). They suffered considerably more congestive heart failure (78.6% vs 10%; p<0.001) and were more likely to undergo surgery during the active phase (71% vs 30%; p=0.006). Echocardiographically, patients who died presented more frequently highly mobile vegetations (63.8% vs 17.8%; p=0.005), massive vegetations (>15mm) (44.4% vs 4.2%; p=0.013), annular abscess (38.5% vs 1.7%; p<0.001), prosthetic dehiscence (42.9%vs 17.3%;p=0.049) and prosthetic abscesses (28.6% vs 3.8%;p<0.001). Conversely, neither age nor causative organisms were associated with in hospital mortality. On multivariate analysis, the only variable strongly correlated with in hospital death was congestive heart failure (HR=27.5, p=0.005, 95% CI [2.78-276.6]). PVE remains very serious condition carrying high mortality rates.In our series, the strongest predictor of mortality was congestive heart failure.