Treatment Of Prosthetic Valve Endocarditis Research Articles

Prognosis of prosthetic valve infective endocarditis due to Streptococcus spp., a retrospective multi-site study to assess the impact of antibiotic treatment duration.

The duration of antibiotic treatment for prosthetic valve endocarditis caused by Streptococcus spp. is largely based on clinical observations and expert opinion rather than empirical studies. Here we assess the impact of a shorter antibiotic duration. To assess the impact of antibiotic treatment duration for streptococcal prosthetic valve endocarditis on 12-month mortality as well as subsequent morbidity resulting in additional cardiac surgical interventions, and rates of relapse and reinfection. This retrospective multisite (N= 3) study examines two decades of data on patients with streptococcal prosthetic valve endocarditis receiving either 4 or 6 weeks of antibiotics. Overall mortality, relapse, and reinfection rates were also assessed for the entire available follow-up period. The sample includes 121 patients (median age 72 years, IQR [53; 81]). The majority (74%, 89/121) received a ß-lactam antibiotic combined with aminoglycoside in 74% (89/121, median bi-therapy 5 days [1; 14]). Twenty-eight patients underwent surgery guided by ESC-guidelines (23%). The 12-month mortality rate was not significantly affected by antibiotic duration (4/40, 10% in the 4-week group vs 3/81, 3.7% in the 6-week group, p=0.34) or aminoglycoside usage (p=0.1). Similarly, there were no significant differences between the 2 treatment groups for secondary surgical procedures (7/40 vs 21/81, p=0.42), relapse or reinfection (1/40 vs 2/81 and 2/40 vs 5/81 respectively). Our study found no increased adverse outcomes associated with a 4-week antibiotic duration compared to the recommended 6-week regimen. Further randomized trials are needed to ascertain the optimal duration of treatment for streptococcal endocarditis.

Aortic allografts for surgical treatment of prosthetic valve endocarditis

Background: Prosthetic valve endocarditis, the most severe form of infective endocarditis, occurs in 1-6% of patients with valve prostheses and is still associated with poor prognosis and high in-hospital mortality.Objective: To assess outcomes of allograft aortic root replacement in patients with prosthetic valve endocarditis.Methods: The retrospective analysis included adult patients with prosthetic valve endocarditis, who underwent allograft aortic root replacement between 2011 and 2022.Results: Of 15 study patients, early infective endocarditis was found in 60.0% of the cases. The most common cause was Staphylococcus aureus (26.7%). Early mortality was 13.3%. Thromboembolic events occurred in 2 patients (13.3%). The median follow-up period was 48.5 (6-140) months. Late death was reported in 1 patient. The 5-year survival rate was 79.0%. One patient had recurrent infective endocarditis. Two patients underwent reintervention: one for a proximal anastomotic pseudoaneurysm and another one for structural degeneration of the allograft. Five-year freedom from reintervention was 91.7%.Conclusion: Due to the high rate of the freedom from recurrent infective endocarditis, allograft aortic root replacement is an effective treatment for patients with prosthetic valve endocarditis. Received 7 November 2022. Revised 9 December 2022. Accepted 20 December 2022. Funding: The study was supported by the grant of the president of the Russian Federation (No. 075-15-2022-823). Conflict of interest: The authors declare no conflict of interest. Contribution of the authorsConception and study design: A.V. Bogachev-ProkophievData collection and analysis: A.V. Karadzha, A.N. Pivkin, A.S. ZalesovStatistical analysis: R.M. Sharifulin, A.V. AfanasyevDrafting the article: R.M. Sharifulin, A.V. AfanasyevCritical revision of the article: A.V. Bogachev-Prokophiev, S.I. ZheleznevFinal approval of the version to be published: A.V. Bogachev-Prokophiev, R.M. Sharifulin, S.I. Zheleznev, A.V. Karadzha, A.V. Afanasyev, A.N. Pivkin, A.S. Zalesov

50+ years later, prosthetic valve endocarditis still confounds.

Key Points Prosthetic valve endocarditis is a rare but important complication of transcatheter aortic valve replacement. Treatment of prosthetic valve endocarditis in patients who are status‐post transcatheter aortic valve replacement is difficult due to antibiotic resistance, and outcomes indicate a mortality >10%. In the absence of clinical trials of effective prophylactic antibiotics at the time of transcatheter aortic valve replacement, a careful search for infection both pre‐ and post‐transcatheter aortic valve replacement is critical to prevent infection and treat infection early.

Feasibility of Low-Seated Composite Aortic Conduit for Surgical Treatment of Prosthetic Valve Endocarditis: A Case Report

Background: A 49-year-old male presented with a delayed diagnosis of infective endocarditis leading to extensive intracardiac destruction. Such cases present technical challenges to operative debridement as crucial anchoring points for replacement conduits are compromised. Case Presentation: Our patient presented at age 49 with nausea, lethargy, and diarrhea 2 weeks after recent travel. His prior history included bioprosthetic valve replacement for a bicuspid aortic valve. The patient was first given a trial of antimicrobials for a suspected UTI. Subsequently, he was admitted briefly to an outside hospital for a “cardiac work-up,” which returned negative. The patient sought care for the third time, during which he developed unstable supraventricular tachycardia, prompting echocardiography 16 days following the onset of symptoms. Echocardiography demonstrated a 6 cm abscess cavity invading the interventricular septum with a fistula into the left ventricular outflow tract, multiple ventricular septal defects (VSD), and suspected fistulae into the right ventricular outflow tract. The patient was treated with valve explant and extensive debridement. A valved-conduit for the aorta could not be sewn to the aortic annulus in the usual fashion due to destruction and debridement of the annulus, so a neo-annulus was created using the anterior leaflet of the mitral valve and the left ventricular outflow tract of the heart below the level of the VSDs. A mechanical-valved conduit was implanted onto the neo-annulus. A pacemaker was subsequently implanted. Conclusion: In patients with extensive intracardiac destruction with the compromise of the aortic annulus due to infective endocarditis, a low-seated, mechanical-valved conduit implanted directly to the aorto-mitral curtain and left ventricular outflow tract should be considered a novel, durable reconstructive option that allows complete debridement of infected tissues.

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.

Experience of treatment of prosthetic valve endocarditis: a retrospective single-center cross-sectional study.

The aim of this study was to describe the experience of treatment of early prosthetic valve endocarditis at a heart center. Retrospective single-center study on data collected from electronic medical records covering the period from January 2009 to December 2015. Over the study period, 1,557 consecutive valve operations were performed on adult patients. The study population comprised 32 patients (2%) who were diagnosed with prosthetic valve endocarditis within 12 months after the index surgery. Medical records were retrieved from electronic hospital records, retrospectively. Descriptive clinical, echocardiographic, microbiological and treatment-type data were used. Risk factors for early mortality were studied through univariate and multivariate analyses. The main clinical manifestation of infective endocarditis was fever, and this was present in all patients. Most of the prostheses were affected in the aortic position (40.6% of cases). The most commonly cultured microorganisms were Staphylococcus epidermidis and Staphylococcus aureus. Twenty-six patients (81.3%) underwent surgical treatment and six (18.7%) underwent exclusive clinical treatment. The prevalence of postoperative complications was 31.3% and hospital mortality occurred in seven cases (21.9%). The mortality rate was 50% among the patients who underwent medical treatment and 15.4% among those who underwent surgery. There were no independent risk factors for mortality. Prosthetic valve endocarditis is an infrequent complication of valve replacement. Surgical treatment has mortality rates compatible with the severity of patients' conditions. Surgical indication should not be delayed when clinical treatment has been ineffective.

COMPARISON OF NON-SURGICAL AND SURGICAL THERAPY FOR PROSTHETIC VALVE ENDOCARDITIS: A PROPENSITY SCORE-ADJUSTED STUDY

Background: Patients with prosthetic valve endocarditis (PVE) who are not treated surgically have poor clinical outcomes. This study was undertaken to compare outcomes of non-surgical with surgical treatment for PVE. Methods: Patients admitted to Cleveland Clinic with PVE from April 1, 2008 to

Outcomes After Exclusive Medical Treatment for Prosthetic Valve Endocarditis

Outcomes After Exclusive Medical Treatment for Prosthetic Valve Endocarditis

Comparison of Medical and Surgical Treatment for Prosthetic Valve Endocarditis: A Propensity Score-Adjusted Study

Comparison of Medical and Surgical Treatment for Prosthetic Valve Endocarditis: A Propensity Score-Adjusted Study

EReply. Towards better understanding and management of Propionibacterium acnes in cases of prosthetic valve endocarditis.

We would like to thank Dr Mestrovic and colleagues for their comments and kind words regarding our paper on prosthetic valve endocarditis (PVE) caused by Propionibacterium acnes (P. acnes). We would like to take this opportunity to further clarify the issues raised in this commentary. We fully agree with Dr Mestrovic and colleagues that the diagnosis of PVE due to P. acnes can be challenging in the clinical setting and would like to take this opportunity to provide further information on our microbiological techniques as requested. Bactec aerobic and anaerobic culture bottles were used. The material was incubated for 14 days at 35 degrees Celsius in the Bactec FX blood culture system (Becton Dickinson). Cardiac valve tissue was incubated 14 days at 35 degrees Celsius on, amongst others, Brucella 5% blood agar anaerobic plates. P. acnes was identified on the basis of colony morphology and identification was confirmed by mass spectrometry (Maldi Biotyper, Bruker). Concerning the question on neurological complications due to P. acnes. As shown in table 2 of our paper 2 patients presented with neurological deficit. These episodes were transient. The percentage of patients is comparable to the generic cohort of patients presenting with PVE in our institute and did not constitute a higher risk of mortality is this small series. The PCR technique can indeed be very valuable to confirm the diagnosis, as Dr Mestrovic argues, and can be performed in difficult cases. However, the technique is costly and is not standard of care in most countries. We would advocate proper culturing with a prolonged incubation time in patients with the likelihood of P. acnes PVE. Using the current literature and our own experience we would not advocate longer terms of antibiotic treatment in patients with P acnes PVE or a conservative approach without surgery. Six weeks should be sufficient. If a patient is inoperable, the idea of suppression therapy with prolonged antibiotics could be entertained. In our series we used a conservative approach in one patient. This patient did not show a dehiscence of his mechanical valve. This seems to be the pivotal point for a potential successful treatment of PVE due to P. acnes without surgery. Lastly, the importance of more studies, as also argued by Mestrovic, is there. In our article we warn about the possible underdiagnoses of P. acnes PVE due to a large differences in incubation durations and the wrongfully presumed innocence of P. acnes

Invited Commentary

Invited Commentary

Initial Experience with Sutureless Sorin Perceval S Aortic Prosthesis for the Treatment of Prosthetic Valve Endocarditis.

The objective of this study is to evaluate results of the initial experience with sutureless Perceval S for active prosthetic valve endocarditis (PVE). From October 2012 to April 2014, f: ve patients underwent surgery for aortic PVE with Perceval S bioprosthesis. There was one in-hospital death (20%). Echocardiography performed at discharge showed excellent hemodynamic performance of Perceval S bioprosthesis. Aortic valve replacement with Perceval S sutureless valve in patients with PVE is a feasible and safe procedure, associated with low in-hospital mortality and good hemodynamic performance of the prosthesis.

Transcatheter implantation of self-expanding valve for failed stentless aortic root bioprosthesis

Although repeat aortic valve replacement (AVR) remains the standard treatment for failed bioprostheses, the feasibility of transcatheter aortic valve implantation (TAVI) has also been demonstrated. We report the successful implantation of a CoreValveTM self expanding aortic prosthesis (Medtronic, Inc) in a patient with a degenerated BioConduitTM stentless valve conduit (Shelhigh, Inc). A 63 year-old man was admitted due to NYHA class IV heart failure symptoms. He had a history of triple percutaneous coronary intervention followed by AVR plus LIMA to LAD grafting. Two years after the first surgery, acute dissection of the ascending aorta occurred and the mechanical valve along with the proximal ascending aorta were replaced by a stentless 25 mm valve conduit. Postoperative mediastinitis and atrio-ventricular block warranted sternum refixation and pacemaker implantation. Another year later, the patient underwent conservative treatment for prosthetic valve endocarditis. On current admission, transthoracic and transoesophageal echocardiography (TTE, TEE) revealed left ventricle (LV) end-diastolic diameter (EDD) of 62 mm and ejection fraction (EF) of 25%. Bioprosthetic cusps were opening well but seemed perforated and had attached two additional structures of ultrasound intensity, irregular shape and high mobility corresponding to organised bacterial vegetations. Consequently, severe aortic regurgitation (AR) was present. On coronary angiography, the arterial graft was occluded and no revascularisation within native coronaries was required. The unfavourable anatomical environment expected after mediastinitis accompanied by high STS scoring (16%) and wide peripheral arteries contributed to a decision to reject reoperation in favour of the transcatheter approach. On multi-detector computed tomography (MDCT), the prosthesis length was 45 mm with significant angulation of neighbouring ascending aorta and coronaries reimplanted 12 mm and 17 mm above the valve (Fig. 1). Laboratory findings excluded active infective endocarditis. After induction of general anaesthesia, a Prostar XL (Abbott) device was introduced into the right common femoral artery. Next, a 26 mm CoreValve prosthesis (the size had been selected according to the inner BioConduit diameter of 22 mm by TEE, standard delivery system) was positioned and deployed in a retrograde manner. Lack of fluoroscopy markers such as calcifications or rigid ring rendered the procedure more TEE-dependent. After completion, no transprosthetic gradient was measured and residual paravalvular AR was trivial. Nevertheless, deficient expansion of the stent frame distal part within the non-pliable BioConduit was noted. The time from arterial puncture to closure was 65 min with 22 min of fluoroscopy, and 180 mL of contrast agent was used. The post-procedural course was uneventful and the patient remained asymptomatic at 12-month follow-up. A remarkable improvement in LV performance was noted, with EDD of 54 mm and EF of 56% by TTE. Repeated MDCT visualised uncompromised coronaries ostia and persistent distal stent frame deformation. Proximal circularity remained however unaffected, which corresponded to the valve’s excellent function (Figs. 2, 3). Initial balloon valvuloplasty may optimise transcatheter valve stent alignment at the expense of degenerated bioprosthesis fragmentation and peripheral embolisation. The anticipated fragility of the thin-walled bioprosthetic cuff further added to our refraining from the manoeuvre. Lack of natural aorta sinus widening in patients with full root prostheses renders coronary flow impairment during TAVI more likely. This was avoided by careful positioning of the CoreValve sealing skirt below the coronaries’ ostia.

The impact of preoperative limb embolisation in active infective left-sided endocarditis

The impact of preoperative limb embolisation in active infective left-sided endocarditis

Aortic Valve Replacement Performed Twice Through Ministernotomy 15 Years After Lung Transplantation

After transplantation, steroids and calcineurin inhibitors together with end-stage renal failure may lead to associated cardiovascular diseases, particularly in long-term survivors. We present a case of aortic valve replacement 15 years after lung transplantation, followed by reoperative valve replacement for late infective endocarditis. Lung compliance and gas exchange were excellent during recovery. Despite adequate prophylaxis, immunosuppression and hemodialysis likely contributed to repeated episodes of sepsis, which caused detachment of the first aortic prosthesis. Despite the high mortality of prosthetic valve endocarditis, the postoperative course was uneventful and the patient is doing well at 24-month follow-up.

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.

Prosthetic valve endocarditis: state of the heart

Prosthetic valve endocarditis (PVE) is a rare but serious complication of cardiac valve replacement surgery and is associated with high rates of morbidity and mortality. Despite significant advances in our understanding of the pathogenesis and management of this disease process, the rates of undesirable outcomes, including mortality directly attributable to infection, remain unacceptably high. The purpose of this article is to provide an up-to-date review of the changing epidemiology, microbiology and pathogenesis of PVE as well as review state-of-the-art diagnostic approaches and treatment for PVE, including the controversies surrounding the role of surgery for optimal management.

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.

A Surgical Case of Prosthetic Valve Endocarditis with a Difficult Diagnosis

Early diagnosis and treatment of prosthetic valve endocarditis (PVE) is important because it has a high mortality rate. We report a case of PVE which was difficult to diagnose. A 36-year-old man, who had undergone an aortic valve replacement (AVR) 7 years prior, was hospitalized with a high fever of unknown origin. We could not detect a stuck valve, vegetations or abscesses using echocardiography, and the peak aortic transvalvular pressure gradient had increased to 81 mmHg. We suspected PVE and initiated intravenous antibiotic therapy immediately. On day 5, echocardiography demonstrated an abnormal shadow directly under the prosthesis, and we definitively diagnosed PVE and performed an operation. Intraoperatively, the prosthesis was not vegetative, but the left ventricular outflow tract was filled with vegetation that was nearly obstructing it. After dissecting the infectious focus, we performed a re-AVR. Postoperative echocardiography showed that the peak left ventricular aortic pressure gradient decreased to 30 mmHg. Obstructive vegetation is difficult to diagnose by preoperative echocardiography.

Surgical treatment of prosthetic valve endocarditis in patients with double prostheses: is single-valve replacement safe?

Bias against operating on patients with prosthetic valve endocarditis (PVE) who have multiple prostheses may preclude the use of life-saving valve replacement. We investigated the accuracy of the preoperative diagnosis of PVE in patients with both mitral and aortic prosthesis and the safety of single-valve replacement when only one valve seemed infected. Patients with a diagnosis of active PVE who had mitral and aortic prosthesis in place were assessed. We looked at the methods for diagnosis, causative agents, indication for valve replacement, operative findings and outcome. Twenty patients, who had both mitral and aortic prostheses and a diagnosis of PVE, were assessed. Streptococci and staphylococci caused 70% of cases. By means of echocardiography, the valves involved were: mitral (11 patients), aortic (six patients), and in three cases both prosthetic valves seemed infected. Surgery was undertaken in 17 patients (85%). The positive predictive value of transesophageal echocardiogram (TEE) for the preoperative diagnosis of the site of infection was 100%. In 13 patients, only the prosthetic valve that seemed infected was replaced. Four of these patients died within a week after the procedure. Nine patients survived the surgical procedure, completed a course of antimicrobial therapy and were followed up for 15.78 months (95% CI: 12.83-18.72). All were considered cured and relapses were not observed. TEE allowed a diagnosis of site involvement that did correlate with the anatomic diagnosis obtained during the operation. This fact contributed to the management of patients and was of great help in guiding the surgical intervention. Echo-oriented single-valve replacement may be a safe strategy for patients with PVE and double prostheses.