Treatment Of Prosthetic Valve Endocarditis Research Articles

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.

Triple-valve treatment for prosthetic valve endocarditis occurring 20 years after implantation of a Carpentier-Edwards pericardial bioprosthesis in the aortic valve

A 68-year-old woman had undergone aortic valve replacement and open commissurotomy 20 years previously. At the beginning of 2008, fever, cold, and heart failure symptoms were noted. On blood culture, Streptococcus oralis was detected three times. Surgery was performed under a diagnoses of prosthetic valve endocarditis in the aortic valve, mitral stenosis and insufficiency, and tricuspid insufficiency. Techniques consisted of additional aortic valve replacement, mitral valve replacement, and tricuspid annuloplasty. Vegetation was macroscopically and pathologically observed in the extirpated Carpentier-Edwards pericardial bioprosthesis that had been placed in the aortic valve. There was no postoperative recurrent inflammatory response. The patient was discharged 32 days after surgery.

Prosthetic valve endocarditis with extensive aortic root abscess

Prosthetic valve endocarditis with an extensive aortic root abscess usually has high mortality and morbidity. A 71-year-old male with an extended aortic root abscess following aortic valve replacement survived after full aortic root reconstruction with glutaraldehyde bovine pericardium, mitral valve replacement and full root replacement using stentless bioprosthesis. The patient is well without recurrence of infection, 18 months postoperatively. This procedure might be an alternative treatment for prosthetic valve endocarditis with an extended aortic root abscess.

Conservative treatment of prosthetic valve endocarditis due to Mycobacterium fortuitum.

Described here is the case of a patient with infective endocarditis in a prosthetic valve due to a Mycobacterium fortuitum-group organism. The patient was treated medically and had a favorable clinical response. This is only the second report of survival after Mycobacterium fortuitum-group endocarditis, and the first of survival without surgical intervention. The duration of treatment is not well defined for this patient, but life-long suppressive therapy will likely be required.

Surgical treatment of prosthetic valve endocarditis: B.W. Lytle, B.P. Priest, P.C. Taylor, F.D. Loop, S.K. Sapp, R.W. Stewart, P.M. McCarthy, D. Muehrcke, D.M. Cosgrove III, D.C. Miller, A. Arbulu, G.D. Pennington. Cleveland Clinic Foundation, Cleveland, OH. J Thorac Cardiovasc Surg 1996;111:198–210

Despite advances in the diagnosis and treatment of prosthetic valve endocarditis (PVE) it remains a serious complication of prosthetic valve replacement. Antibiotic treatment alone can be successful for late infections that involve the prosthesis only (particularly for patients with bioprothesis), but it rarely cures infections involving the valve-native annulus interface. Combined antibiotic and surgical treatment of PVE often is successful; more accurate diagnosis (usually based on echocardiography), more effective myocardial protection at reoperation, and improved surgical experience have improved the short-term and long-term outcomes for patients with PVE. For 146 patients of Cleveland Clinic Foundation who underwent reoperation for PVE from 1975 through 1992, the overall in-hospital mortality rate was 13%, 10% from 1985 to 1992. In this more recent surgical period, active infection and early PVE did not appear to be factors that increase in-hospital mortality. The mean in-hospital stay of survivors was 25 days, which highlights the fact that even successful treatment of PVE uses enormous resources. The late survival rate of in-hospital survivors was 82% at 5 years, and the reoperation-free survival rate was 75% at 5 postoperative years.

Oral antibiotic therapy in infective endocarditis.

The mortality of IE remains fairly high despite the aggressive use of intravenous antibiotics. Oral treatment of IE is an intriguing concept with many potential advantages over conventional intravenous therapy. Unfortunately, there are insufficient data to justify predominantly oral regimens for the treatment of IE. Trials have shown that oral therapy may have a role in follow-up to short courses of parenteral antibiotics, but these trials are limited by the small number of patients studied. It is important to note that most data for oral treatment of IE have been obtained from studies in patients with histories of IVDA and right-sided S. aureus endocarditis. As mentioned previously, the course of IE in this patient population tends to be less severe, which makes extrapolation of these data to the general population difficult. A need exist for the development of oral antimicrobials with the properties previously mentioned, making them appropriate for use in IE. Currently available oral agents require further study before general recommendations regarding their use in patients with IE can be made. Although successful oral treatment of prosthetic valve endocarditis has been reported, such patients in general should not be considered as appropriate candidates for oral therapy. For now, oral antimicrobial therapy may be appropriate only as follow-up to short-course intravenous therapy, or use in combination with intravenous therapy for IE in select populations whose disease course is less severe or in whom prolonged intravenous therapy is impractical (i.e., intravenous drug users).

Surgical treatment of prosthetic valve endocarditis

From 1975 through 1992, we reoperated on 146 patients for the treatment of prosthetic valve endocarditis. Prosthetic valve endocarditis was considered to be early (<1 year after operation) in 46 cases and active in 103 cases. The extent of the infection was prosthesis only in 66 patients, anulus in 46, and cardiac invasion in 34. Surgical techniques evolved in the direction of increasingly radical débridement of infected tissue and reconstruction with biologic materials. All patients were treated with prolonged postoperative antibiotic therapy. There were 19 (13%) in-hospital deaths. Univariate analyses demonstrated trends toward increasing risk for patients with active endocarditis and extension of infection beyond the prosthesis; however, the only variables with a significant (p < 0.05) association with increased in-hospital mortality confirmed with multivariate testing were impaired left ventricular function, preoperative heart block, coronary artery disease, and culture of organisms from the surgical specimen. During the study period, mortality decreased from 20% (1975 to 1984) to 10% (1984 to 1992). For hospital survivors the mean length of stay was 25 days. Follow-up (mean interval 62 months) documented a late survival of 82% at 5 postoperative years and 60% at 10 years. Older age was the only factor associated (p = 0.006) with late death. Nineteen patients needed at least one further operation; reoperation-free survival was 75% at 5 and 50% at 10 postoperative years. Fever in the immediate preoperative period was the only factor associated with decreased late reoperation-free survival (p = 0.032). Prosthetic valve endocarditis remains a serious complication of valve replacement, but the in-hospital mortality of reoperations for prosthetic valve endocarditis has declined. With extensive débridement of infected tissue and postoperative antibiotic therapy, the extent and activity of prosthetic valve endocarditis does not appear to have a major impact on late outcome, and the majority of patients with this complication survive for 10 years after the operation. (J T HORAC C ARDIOVASC S URG 1996;111:198-210)

Prevention of prosthetic valve endocarditis by impregnation of gentamicin into surgical pledgets

A novel drug delivery system was developed for the treatment of prosthetic valve endocarditis (PVE). The antibiotic, gentamicin, was impregnated into surgical pledgets using non-solvent coacervation of polylactic acid (PLA) as a binding/encapsulating agent. The in vitro dissolution profiles show controlled release of gentamicin for up to 36 h when PLA of molecular weight 2000 is used and up to 7 d for PLA with a molecular weight of 50000. The results indicate potential for the localized treatment of PVE, which is cost-effective, easy to manufacture and permits dosage variability.

Surgical Treatment of Prosthetic Valve Endocarditis with Homograft Aortic Valve Replacement

This article presents the University of Alabama experience with homograft aortic valve replacement for prosthetic valve endocarditis. Of 117 patients who have undergone homograft aortic valve replacement since 1981, there has been a total of 22 patients who underwent operation for endocarditis. Sixteen were isolated valve replacements, three combined with other procedures, and three were aortic root replacements. When placed in a setting of active endocarditis, there have been no reoperations for endocarditis of the homograft valve. Surgical techniques are presented for the freehand sewn homograft as well as aortic root replacement. Prosthetic valve endocarditis is a highly lethal event and when aortic valve replacement is advised in this setting, we believe a homograft aortic valve should be implanted whenever possible.

ＰＶＥの外科治療 とくに房室弁位におけるｔｒａｎｓｌｏｃａｔｉｏｎ法施行症例を中心に

ＰＶＥの外科治療 とくに房室弁位におけるｔｒａｎｓｌｏｃａｔｉｏｎ法施行症例を中心に

Prosthetic Valve Endocarditis Caused by Brucella melitensis

Optimal treatment of prosthetic valve endocarditis due to Brucella melitensis is unknown. The presence of ring abscess makes extensive surgical débridement and valve replacement essential steps of management. Antimicrobial therapy with tetracycline hydrochloride plus streptomycin sulfate or sulfamethoxazole and trimethoprim can achieve the sterilization of infected cardiac tissue. Late bland periprosthetic leaks occur frequently. Reoperation can be safely performed after a period of antimicrobial therapy. Prolonged treatment with doxycycline hyclate seems advisable.

Treatment of prosthetic valve endocarditis.

Prevention of early prosthetic valve endocarditis (PVE) depends on rational perioperative antibiotics and early aggressive treatment of wound infections. Successful treatment depends on rapid recognition and treatment and valve re-replacement in most instances. Late PVE caused by sensitive organisms can usually be cured by medical treatment provided paraprosthetic abscess formation has not caused valve dehiscence.

Prosthetic valve endocarditis.

About 2% of patients with a prosthetic valve will develop endocarditis. This may occur within a few weeks of the valve replacement operation (early) or many months or years later (late). The infecting organisms, pathogenicity and prognosis differ in the two groups. The incidence of early prosthetic valve endocarditis (PVE) is under 1%; the predominant organisms are staphylococci that are acquired in the operating theatre or in the intensive therapy unit. Early PVE usually follows wound sepsis that may initially appear trivial. The mortality rate is around 70%, but such infections should be preventable by stringent antisepsis, good surgical technique and (perhaps) perioperative antistaphylococcal antibiotics. The incidence of late PVE is about 1% per annum. The infecting organisms are similar to those causing native valve endocarditis, predominantly streptococci. The commonest source of these organisms is the mouth and regular dental care and appropriate prophylactic antibiotics should help to prevent infection. The mortality rate of late PVE is around 10%. Failure of medical treatment in PVE is an indication for surgery to remove the infected valve(s) and this should not be delayed. The optimum length of treatment for PVE is unknown but it is seldom necessary to give antibiotics for more than 6 weeks except in Coxiella burnetii infection.

代用弁置換後感染性心内膜炎に対する断層心エコー法による診断と外科治療の問題点

代用弁置換後感染性心内膜炎に対する断層心エコー法による診断と外科治療の問題点

置換弁心内膜炎の検討

置換弁心内膜炎の検討

Duration of symptoms and the effects of a more aggressive surgical policy: two factors affecting prognosis of infective endocarditis.

One hundred and six patients were analysed in order to assess the effect of a more aggressive surgical policy in relation to the delays in diagnosis of infective endocarditis. The average duration of symptoms before diagnosis was 9.7 weeks, even though the patients had sought medical advice at a relatively early stage of their illness (2.2 weeks). Three of the 29 (10.3%) patients who were treated surgically died and all three were operated upon five weeks or later after diagnosis. Seventy-seven patients did not have surgery and 15 died (19.5%). The outcome of surgical treatment for prosthetic valve endocarditis was no worse than for native valve endocarditis. The mortality of prosthetic valve endocarditis including early infections was 32% with medical but only 10% with surgical management compared with 14.5% and 10.5% in native valve endocarditis. Endocarditis cannot always be prevented but earlier diagnosis would reduce mortality and prevent complications. When medical treatment is failing then surgery should be considered early and urgently particularly in staphylococcal infection or when large mobile vegetations are recognized; surgery is mandatory in fungal endocarditis. Earlier diagnosis would greatly reduce the current high incidence of surgery, but that depends on a much heightened index of suspicion amongst both general practitioners and hospital physicians.

Early and late prognosis after reoperation for prosthetic valve replacement

From 1969 to 1983, 89 patients underwent replacement of a prosthetic heart valve, an average of 66 months after initial implantation, because of primary failure of the prosthesis in 39 patients (44%), endocarditis in 16 (18%), systemic valve-related complications in 16 (18%), and periprosthetic leaks in 13 (15%). In the remaining five patients (5%), a prosthesis was removed concomitantly with the replacement of another native heart valve. A mechanical valve was replaced in 64 cases (72%) and a bioprosthesis in 25 (28%). Forty-six of the prostheses (52%) were in the mitral position, 37 (42%) were in the aortic position, and six patients (6%) underwent replacement of two prostheses. Preoperatively, four patients were in Functional Class I, 21 in Class II, 37 in Class III, and 27 in Class IV. There were 19 early deaths (21.3%). Early mortality was significantly higher with aortic (35.1%) than with mitral prosthetic valve replacement (8.7%, p less than 0.01). Preoperative diagnosis had a significant correlation with mortality, which was higher with infective endocarditis (62.5%) than with all other indications for operation (12.3%, p less than 0.001). No correlation was found with the preoperative clinical class of the patients. During the time period of this study, there was a marked decline in the mortality rate, which decreased from 29.2% prior to 1979 to 7.4% during the last 2 years (p less than 0.05). Actuarial survival was 60% at 5 years and 38% at 10 years after reoperation. Among the 53 survivors followed up for an average of 39 months, 47 (88.9%) remained in Class I or II and six were in Class III (11.3%) at last follow-up. A second prosthetic valve replacement (third valve replacement) was required in eight patients, three of whom died at re-replacement. Recent improvements in myocardial protection techniques, in the treatment of prosthetic valve endocarditis, and increased surgical experience have contributed to decrease the risk of reoperation for prosthetic valve replacement. Late results are similar to those of a first valve implantation.

Successful Surgical Treatment of Prosthetic Valve Endocarditis and Aortic Root Abscesses

Repeated aortic prosthetic valve endocarditis and aortic root abscesses were successfully treated by implantation of a valved conduit into the ascending aorta and by placement of saphenous vein grafts to the aorta distal to the conduit and to the right and left anterior descending coronary arteries. This procedure provides several advantages, and six months after operation, the patient was in a satisfactory hemodynamic state and free from infection.

Perioperative antibiotic prophylaxis and prosthetic valve endocarditis.

A study of twenty-five cases of prosthetic valve endocarditis suggests that the antibiotics used for perioperative prophylaxis may alter the type and antibiotic sensitivity of organisms which subsequently infect the artificial valves. Based on the results of this study, the authors have been able to modify their prophylactic regime to encompass these organisms and to predict the antibiotics most likely to be effective in the treatment of prosthetic valve endocarditis in their unit. No single prophylactic or therapeutic regime will be equally effective in all centres, but by examining the different types and sensitivities of bacteria which cause prosthetic valve endocarditis in a locality, antibiotic regimes can be chosen which best suit the local situation.

Prosthetic valve endocarditis.

From January 1963 until January 1974, 45 patients had prosthetic valve endocarditis. Symptoms of prosthetic valve endocarditis developed within 2 months after operation (early onset) in 16 patients (36%) and more than 2 months after operation (late onset) in 29 patients (64%). Overall mortality among the 45 patients was 56% (88% among those with early onset and 40% among those with late onset). Medical therapy alone was curative in 60% of the surviving patients. Combined medical and surgical therapy was curative in 40% of the survivors. The most frequent isolates in the early-onset group were Staphylococcus aureus (44%) and Gram-negative bacilli (38%); associated mortality was 86% and 83%, respectively. The most frequent isolates in the late-onset group were viridans streptococci (41%) and Gram-negative bacilli (31%); the mortality was 25% and 22% respectively. Suggestions are offered for operative antimicrobial prophylaxis and for medical and surgical treatment of prosthetic valve endocarditis. Prompt surgical replacement of an infected prosthesis is necessary when medical therapy fails.