Long term follow up of prosthetic valve endocarditis: what characteristics identify patients who were treated successfully with antibiotics alone?

Abstract

Objective-To identify predictors for the safe use of antibiotic treatment without reoperation in patients with prosthetic valve endocarditis. Setting-Retrospective study in a tertiary care centre. Subjects and design-All 49 episodes of definite prosthetic valve endocarditis (Duke criteria) diagnosed at one institution between 1980 to 1997 were analysed. Ten episodes (20%) were treated with antibiotics only (antibiotic group) and 39 episodes (80%) with combined antibiotic and surgical treatment (surgery group). The analysis included detailed study of hospital records and data on long term follow up which were obtained in all patients by a questionnaire or telephone contact with physician or patient. The length of follow up (mean (SD)) was 41 (32) months in the antibiotic group and 45 (24) months in the surgery group (NS). Long term survival was estimated by the Kaplan-Meier method and compared by the log-rank test. Results-There was no significant diVerence in age, history of previous endocarditis, number of previous heart operations, vegetations, emboli, type of prosthesis, or percentage of early prosthetic valve endocarditis and positive blood cultures between the two groups. In the antibiotic group, there were more enterococcal (50%; p = 0.005) and in the surgery group more staphylococcal infections (55%; p = 0.048). Annular abscesses (p < 0.0001) and aortoventricular dehiscence (p = 0.02) were more common in the surgery group. No patient in the antibiotic group had heart failure. Long term follow up showed no significant diVerence between the surgery and antibiotic groups regarding late mortality (14% v 18%) and five year rates of recurrent endocarditis (14% v 16%), event related mortality (14% v 3%, log-rank test), and the need for reoperation (14% v 19%; log-rank test). The only patient with conservatively treated staphylococcal prosthetic valve endocarditis died after reoperation for recurrence. Conclusions-Haemodynamically stable patients with non-staphylococcal prosthetic valve endocarditis who are carefully supervised can be treated with antibiotics alone without an increased rate of reinfection, reoperation, or death. (Heart 1999;82:714-720)

2015 ESC Guidelines for the management of infective endocarditis

“…Alternatywnie można zastosować dakronowy konduit zastawkowy [336]. Najkorzystniejszy sposób postępowania terapeutycznego w PVE wciąż podlega dyskusji [221,[354][355][356][357][358][359]. Aczkolwiek, kiedy PVE powoduje ciężką dysfunkcję protezy lub HF, zasadniczo za najlepszą opcję uważa się leczenie chirurgiczne [220]; na podstawie danych z badania Euro Heart Survey [54], operację przeprowadzono tylko w 50% przypadkach PVE, czyli podobnie jak w przypadku NVE.…”

“…Operacja w trybie nagłym jest wskazana tylko w przypadku opornej zastoinowej HF prowadzącej do wystąpienia obrzęku płuc lub wstrząsu kardiogennego, podobnie jak w NVE. Odwrotnie, pacjentów z implantowaną sztuczną zastawką i niepowikłanym, niegronkowcowym i niegrzybiczym późnym zapaleniem wsierdzia można leczyć zachowawczo [350,357,358]. Jednak chorych, których wstępnie poddano farmakoterapii należy ściśle monitorować ze względu na ryzyko późnych powikłań.…”

Staphylococcus aureus Infections: Epidemiology, Pathophysiology, Clinical Manifestations, and Management

“…Several studies have concluded that all patients with S. aureus prosthetic valve IE, regardless of whether they have complications, benefit from surgery, citing the lower mortality rates found with the combination of medical and surgical treatments (146,152,153,183,(229)(230)(231)(232). For example, Fernandez Guerrero et al found that of the 65% of patients who underwent valve replacement surgery, only 15% died, whereas all of the 35% of patients who did not receive surgery died (146).…”

Late Postoperative Prosthetic Pulmonary Valve Endocarditis in a 13-Year-Old Girl with Repaired Tetralogy of Fallot

“…23 Prosthetic valve endocarditis has been successfully treated with antibiotics alone. 6,24 However, the addition of surgical treatment is thought to improve outcomes, particularly when endocarditis is associated with S. aureus, congestive heart failure, prosthetic dehiscence, valve dysfunction, intracardiac abscess formation, or persistent bacteremia. 25,26 Our patient's incomplete re sponse to intravenous antibiotics, along with the follow up echocardiogram that confirmed the endocarditis and showed pulmonary emboli, prompted our explanta tion of the infected valve.…”