Paravalvular Abscess Research Articles

Clinical outcome and long-term prognosis of late prosthetic valve endocarditis: a 20-year experience.

A prospective study of the clinical characteristics and evolutionary patterns of 59 cases of late prosthetic valve endocarditis (LPVE) that occurred between January 1975 and December 1994 was performed. Of these 59 cases of LPVE, 48 involved mechanical valves and 11 involved biological valves. Etiologies were as follows: streptococci, 41% of cases; staphylococci, 25%; enterococci, 13%; and miscellaneous, 21%. Echocardiography documented vegetations in 21 patients, paravalvular abscesses in 10, and prosthetic leaks in 34. Emboli occurred in 22 patients, and heart failure in 19 patients. Forty-two patients received medical treatment alone, and 17 received medical treatment and underwent valve replacement surgery. The in-hospital mortality rate was 25%; staphylococcal infection caused 67% of deaths, streptococcal infection caused 5%, and other etiologies caused 23% (P = .0004). After adjustment for age and type of prosthesis, multiple logistic regression revealed an odds ratio for death due to nonstreptococcal infections of 9.67. The overall survival rate was 59% at 5 years and 52% at 10 years. During follow-up, 17 patients needed new valves. At the end of follow-up, only 13 patients remained alive and had the same prosthesis that they had at the time of the diagnosis of LPVE.

Long-term results of surgery for active infective endocarditis.

This paper was undertaken to determine the long-term outcome of active infective endocarditis treated with antibiotic and radical excision of infected tissues by surgery. From October 1978 to August 1994, 122 consecutive patients were operated on during the acute phase of infective endocarditis. There were 85 men and 37 women whose mean age was 50 years, ranging from 20 to 79. Surgery was needed because of one or more of the following complications: cardiogenic/septic shock in 19 patients, congestive heart failure in 68, persistent sepsis in 64, peripheral embolization in 20, and cerebral embolization in 10. The offending microorganism was identified in 110 patients, staphylococci were the most common ones. Seventy-six patients had native valve endocarditis and 46 had prosthetic valve endocarditis. Simple valve replacement or repair was performed in 60 patients and radical resection of the valve and surrounding tissues with reconstruction of the heart with either fresh autologous pericardium or glutaraldehyde-fixed bovine pericardium was performed in 62 with paravalvular abscess. Pulmonary autograft and aortic homograft were used in only three patients, the remaining patients had either bioprostheses or mechanical heart valves if valve repair was not feasible. There were nine deaths, for an operative mortality of 7.4%. Logistic regression analysis identified preoperative shock and renal failure as predictors of operative mortality. Operative survivors were followed up from 4 to 173 months, mean of 56.4. The actuarial survival at 10 years was 61 +/- 6%. Logistic regression analysis identified preoperative New York Heart Association functional class IV and perioperative renal failure as predictors of late mortality. Eight patients developed recurrent endocarditis 10-102 months postoperatively. The freedom from recurrent endocarditis at 10 years was 79 +/- 9%. All patients who developed this late complication had paravalvular abscess at the time of original operation. These data suggest that surgery for active infective endocarditis yield a high probability of eradicating the infection with relatively low operative mortality and good long-term results.

Long-term results of operation for paravalvular abscess

Operation for infective endocarditis with paravalvular abscess is reportedly associated with high mortality and morbidity rates. In an attempt to improve surgical outcome, an approach of radical resection of the abscess and inflamed tissues and reconstruction of the heart with either fresh or glutaraldehyde-fixed bovine pericardium was adopted by two surgeons at our institution. From 1979 to 1995, 70 consecutive patients with active infective endocarditis and paravalvular abscess underwent operation. Their mean age was 49 years (range, 16 to 75 years), and 50 patients (71%) were men. Thirty-four patients had native and 36 had prosthetic valve endocarditis (8 had had composite replacement of the aortic valve and ascending aorta). Most patients (78%) were in New York Heart Association functional class IV. The principal indication for operation was cardiogenic or septic shock in 11 patients, or one or more of the following: persistent sepsis despite adequate antibiotic therapy in 36, congestive heart failure in 31, and recurrent emboli in 16. Staphylococci were responsible for the infection in 37 patients (53%). The abscess was in the mitral annulus in 11 patients, in the aortic root in 44, and in the aortic root and at least one other annulus in 15. After wide resection of the abscess, we reconstructed the heart and annuli with autologous or bovine pericardium. Mechanical heart valves were implanted in 36 patients, bioprostheses in 30, and aortic homografts in 2; valve repair was possible in 2. Sixteen patients required composite replacement of the ascending aorta and aortic valve. There were 9 operative deaths (13%). Infections caused by staphylococci and infections in multiple annuli were associated with increased operative mortality rates. Only 1 patient had persistent infection and required reoperation. The mean follow-up was 56 +/- 40 months. There were 12 late deaths, mostly cardiac. The actuarial survival including operative deaths was 64% +/- 8% at 8 years. In 8 patients, recurrent infective endocarditis developed 10 to 102 months after operation. The freedom from recurrent endocarditis was 76% +/- 10% at 8 years. This experience indicates that radical resection of the abscess and reconstruction of the heart with pericardium yield an excellent chance of eradicating the infection in patients with infective endocarditis and paravalvular abscess. The type of valve implanted may not be as important as radical resection of the abscess. These patients appear to have a greater than average risk of recurrent endocarditis.

Surgical treatment of acute endocarditis of the aortic valve with paravalvular abscess: considerations justifying the use of mechanical replacement devices

Early recurrency after surgery for acute endocarditis is a life-threatening complication. Allograft valves are supposed to have a higher resistance to recurrent infection, thus several authors claim them to be the replacement device of choice in cases of aortic endocarditis. However, allografts have two major drawbacks: their availability is limited, and most of the patients require reoperation for graft calcification of degeneration. Until now there has been no prospective study analysing whether early recurrency after surgery of acute endocarditis is associated with the mechanical valve per se or with factors related to the surgical technique or postoperative care. We present a prospective study on 36 consecutive patients with acute endocarditis of the aortic valve with paravalvular abscesses. In this series, there were 5 women and 31 men with a mean age of 50.3 years. All patients were operated before a course of antibiotic therapy was completed. Abscesses were radically resected and the cavities closed either with direct suture or, if not possible, with Dacron patches. For aortic valve replacement, a mechanical valve was used in every patient. The early mortality in this series was 14%, only one patient experienced recurrent endocarditis and underwent reoperation. The results compare well with those achieved after valve replacements with allograft valves. We conclude that, even in cases of acute endocarditis, replacement of the aortic valve with a mechanical device is an acceptable alternative to the allograft, if radical surgical debridement and adequate antibiotic therapy are performed.

Echocardiographic assessment of vegetations in patients with infective endocarditis: prognostic implications.

Today, echocardiography is the most important technique next to clinical findings and blood cultures in the diagnosis of infective endocarditis. The sensitivity of echocardiography, particularly the transesophageal approach, for detection of vegetations and endocarditis related valvular destructions is high. In addition, echocardiographic findings may have some prognostic implications. The size and mobility of vegetations stratifies endocarditis patients into a high risk group for arterial embolism. In particular, mobile vegetations attached to the mitral valve with a maximal diameter > 10 mm may be prone to embolic events. Furthermore, increase in size of vegetations during antimicrobial treatment may identify patients with no, or at least a prolonged, healing process. Also, a lack of increase in the echo density of vegetations under adequate antibiotic treatment may indicate a poor healing process and may necessitate more aggressive management. The demonstration of paravalvular abscesses by echocardiography, particularly by transesophageal echocardiography, identifies a subgroup of patients who will need urgent cardiac surgery before widespread tissue destruction has occurred.

Endocarditis-Associated Paravalvular Abscesses: Do Clinical Parameters Predict the Presence of Abscess?

To determine whether standard clinical and transthoracic echocardiographic criteria considered to be suggestive of the presence of endocarditis-associated paravalvular abscess are predictive of which patients would benefit from reliable but invasive transesophageal echocardiographic investigations for abscess. Retrospective chart review. A 630-bed university hospital. Forty-eight patients with 51 episodes of definite endocarditis and 24 paravalvular abscesses. A comparison of abscess and nonabscess populations revealed that clinical parameters (patient demographics, valvular involvement, presence of a prosthesis, infection with a virulent organism, pericarditis, persistent fever, persistent bacteremia, congestive heart failure, history of intravenous drug use, embolization) and transthoracic echocardiographic parameters were insensitive predictors of the presence of abscess. The only statistically significant correlate was the presence of previously undetected atrioventricular or bundle branch block. Paravalvular abscesses were common in our population and were associated with increased mortality. Improved survival correlated with the absence of mitral valve involvement and the absence of moderate-to-severe congestive heart failure. Given the accuracy and safety of transesophageal echocardiography and the unreliability of clinical and transthoracic echocardiographic criteria, we recommend that transesophageal echocardiography be considered in all endocarditis patients with previously unrecognized conduction disturbances, aortic or prosthetic valve involvement, or both, or indications for valve replacement, or all of the foregoing.

ECHOCARDIOGRAPHIC DETECTION OF CARDIAC VALVE VEGETATIONS AND PROGNOSTIC IMPLICATIONS

Echocardiography is a well-established method for diagnosis of vegetations in patients with infective endocarditis. The sensitivity for detection of valvular vegetations depends on the technique used (M-mode, 2D) and is highest for the transesophageal approach (above 90%). Transesophageal echocardiography has been very helpful in patients with suspected endocarditis but a negative transthoracic echocardiogram, and in patients with suspected pulmonary and prosthetic valve endocarditis. Specificity of echocardiography is relatively low in unselected patients, but echocardiography has a high diagnostic yield in preselected patients with clinically suspected active endocarditis. Besides the visualization of vegetations, echocardiography (including Doppler) is the method of choice in the diagnosis of endocarditis-associated complications, e.g., valvular destruction with subsequent severe regurgitation, secondary "jet" or "kissing" lesions, and paravalvular abscesses. The diagnostic power of echocardiography in the detection of paravalvular abscesses and abscess-related complications has been substantially improved with the transesophageal approach. In addition, echocardiographic findings may have prognostic implications. The size and mobility of vegetations stratifies endocarditis patients into a high-risk group for arterial embolism. Furthermore, increase in size of vegetations during antimicrobial treatment may identify patients with no, or at least a prolonged, healing process. Thus, echocardiography has an important diagnostic and prognostic impact in patients with infective endocarditis and is today an established adjacent technique to clinical findings and blood cultures.

Transesophageal echocardiography for prosthetic valve evaluation: is it always necessary?

Transesophageal echocardiography provides excellent images of mitral and aortic prostheses, due to its higher resolution and less interference from other cardiac structures. Since the introduction of transesophageal echocardiography, it has proved to be valuable for the evaluation of prosthetic heart valves. "Classic" indications include the evaluation of prosthetic valve endocarditis, the search for paravalvular abscesses, and the assessment of regurgitation in mechanical, especially mitral, prostheses. New technical developments such as biplane or multiplane transducers enhance the diagnostic capabilities of the technique. Transesophageal echocardiography can also have advantages in recognizing obstructive lesions such as thrombi or pannus, and help understand the complex morphology of prostheses in grafts. Transesophageal echocardiography should be considered a backup technique whenever transthoracic echocardiography, which always remains the primary approach, is inconclusive or negative in the presence of clinically suspected prosthetic valve malfunction.

Infective endocarditis

Infective endocarditis is being observed with increased frequency in patients presenting with specific risk factors, such as intravenous drug abuse, human immunodeficiency virus, congenital heart defects, degenerative valve disease, heart surgery, pacemaker implantation, and therapeutic immunosuppression due to organ transplantation. In children, infective endocarditis has changed, with half of the cases occurring nowadays after surgery for congenital heart disease. Infective endocarditis complicates the natural history of hypertrophic cardiomyopathy in 5% to 9% of cases. Transesophageal echocardiography is highly accurate in the detection of complications, such as paravalvular abscesses or mycotic aneurysms, that are frequent in native aortic valve endocarditis. Embolus is the most common extracard iac complication associated with infective endocard it is; valvular vegetations seem to be a significant risk factor for embolism only in case of infection with Streptococcus viridans. Abdominal computed tomography is indicated for monitoring splenic involvement in septic infarcts and abscesses. Cerebrovascular accidents occur in nearly 10% infective endocarditis of the left-sided heart, and a similar incidence was found in patients receiving anticoagulants and in patients who did not. Early surgery in native left-sided endocarditis was accomplished with only 4% hospital mortality and 6% late mortality. Aggressive surgery is recommended even in very ill patients. Homograft aortic root replacement for active aortic prosthetic endocarditis showed a favorable outcome.

Magnetresonanztomographie bei Patienten mit Herzklappenersatz

Artificial valve prostheses are often regarded as a contraindication for magnetic resonance imaging (MRI), although preliminary in vitro studies suggested, that patients with these metallic implants might safely undergo MR examination. This study reports on the experience with a group of 89 patients with 100 heart valve prostheses who were examined by spin-echo MR and gradient-echo MR. MR examination was performed in all patients without complications. The spin-echo sequence showed advantages in the depiction of anatomical structures like paravalvular abscesses. Anatomical structures adjacent to the artificial valve were clearly visible and the metal components of the valves showed no or only small artifacts. Artifacts were accentuated when using gradient-echo sequences. Gradient-echo sequences provided valuable information regarding the presence of valvular insufficiency. Physiological valvular regurgitation was easy to differentiate from pathological paravalvular or transvalvular regurgitation. These results demonstrate that patients with artificial valve prostheses can be imaged by MR without risk and that prosthesis-induced artifacts do no interfere with image interpretation.

Spontaneous Drainage of Paravalvular Abscess Diagnosed by Transesophageal Echocardiography

Paravalvular abscesses, which occur in up to 30% of cases of native valve endocarditis, are being detected with increasing frequency with the use of transesophageal echocardiography. Abscesses of the mitral aortic intervalvular fibrosa have been described but only in association with native or prosthetic aortic valve endocarditis. We describe a patient with native mitral valve endocarditis complicated by an abscess in the fibrosa. A 51-year-old diabetic man presented with Staphylococcus aureus mitral valve endocarditis. A transesophageal echocardiographic study done 8 days after admission revealed two large masses at the base of the anterior mitral leaflet with extension into the fibrosa consistent with a paravalvular abscess that was not detected by precordial echocardiography. A repeat transesophageal echocardiographic study done 20 days after admission showed spontaneous drainage of the abscess and a subsequent fistula between the left atrium and left ventricle. This case highlights the important role that transesophageal echocardiography has in suspected and known cases of endocarditis. Its major advantage of delineating posterior cardiac structures allowed accurate diagnosis and serial evaluation of this previously unreported complication of endocarditis.

Infective endocarditis, 1983–1988: Echocardiographic findings and factors influencing morbidity and mortality

The echocardiograms and clinical records of 70 patients with infective endocarditis seen between 1983 and 1988 were examined to evaluate the role of two-dimensional and Doppler echocardiography in the diagnosis of infective endocarditis and identify risk factors for morbidity and mortality. A blinded observer reviewed the echocardiograms for the presence and size of vegetations and the severity of the valvular regurgitation. Vegetations were identified in 54 (78%) of 69 technically satisfactory echocardiograms. In 38 patients whose heart was examined at surgery or autopsy, all vegetations diagnosed by echocardiography were confirmed, but six additional vegetations were found. Abnormal (greater than or equal to 2+) valvular regurgitation was present in 88% of patients. No patient with less than or equal to 1+ regurgitation (n = 8) died or required valve surgery for heart failure, but three of the eight patients did undergo surgery for mycotic aneurysm, recurrent embolism or paravalvular abscess. In patients without embolism before echocardiography, there was a trend toward a greater incidence of subsequent embolism in those with vegetations greater than 10 mm in size (26% [8 of 31] compared with 11% [2 of 18] with vegetations less than or equal to 10 mm) (p = 0.19). By multivariate analysis, risk factors for in-hospital death (n = 7) were an infected prosthetic valve (p less than 0.007), systemic embolism (p less than 0.02) and infection with Staphylococcus aureus (p = 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Pneumococcal Endocarditis in Adult Patients. A Report of Five Cases and Review of the Literature

A retrospective survey of patients with pneumococcal infective endocarditis at the University Hospital, Leiden, over a 10-year period (1976-1986) yielded five cases. Applying strict case definitions, four patients had definite and one patient possible pneumococcal endocarditis. The commonest presenting signs and symptoms were malaise, fever, and congestive heart failure. Predisposing conditions were previous splenectomy in one case and a valve prosthesis in another. The aortic valve was the most common site of infection. In four of the five patients the diagnosis of endocarditis was made during life. These patients were treated appropriately, i.e. with antibiotics to which S. pneumoniae is sensitive. In three patients, surgical intervention was performed in the acute phase because of progressive heart failure. Paravalvular abscesses were observed at surgery in all these cases. The four patients treated in our series recovered fully; the single fatal case constituted an unrecognized case of pneumococcal endocarditis. If recognized and treated appropriately (particularly with early selective surgery) endocarditis can be cured. In a statistical analysis of 36 patients with pneumococcal endocarditis reported during the past five years, we found a significantly higher occurrence and mortality in men than in women; no other clinical features were associated with a poor outcome of illness.

Modified Danielson technique for recurrent aortic valve endocarditis

Recurrent aortic valve endocarditis is frequently associated with paravalvular ring abscess that destroys the annulus. In occasional cases, the degree of necrosis, destruction of the annulus, and the presence of intramyocardial abscesses make it impossible to seat a new prosthesis. Danielson reported initial success in treating such patients by translocating the aortic valve to the ascending aorta and placing vein grafts to the coronary arteries. We recently treated a 17-year-old patient suffering recurrent aortic valve endocarditis using Danielson's technique, which we modified by implanting the left main coronary artery directly into the conduit. We believe that in young patients this modification can offer a beneficial alternative.