Valvular heart disease
Management of Prosthetic Valve Infective Endocarditis

https://doi.org/10.1016/j.amjcard.2007.12.015Get rights and content

This study analyzed the profile and outcome of surgically versus medically treated patients with prosthetic valve infective endocarditis (PVE). From 2000 to 2006, 80 patients >16 years of age (median 71) with definite PVE according to modified Duke criteria were included. The medically treated group was separated into deliberately conservative and perforce conservative treatments, the latter group including patients with contraindications to a cardiosurgical intervention. The most frequent causative micro-organisms were staphylococci. Forty-six percent of patients were surgically treated, 34% had deliberately conservative treatment, and 20% had perforce conservative treatment. Six-month mortality was 29%; 27% of surgically treated patients died, 4% deliberately conservatively patients died, and 75% perforce conservatively treated patients died. Septic shock, multiorgan failure, and type of treatment were significantly associated with death in univariable analysis. Multivariable analysis revealed that type of treatment (perforce conservative) and septic shock predicted death in patients with PVE. Survival was most favorable in deliberately conservatively treated patients, including PVE due to Staphylococcus aureus. In conclusion, there remains a role for watchful waiting in patients with PVE without evidence of major complications. Moreover, patients with uncomplicated S. aureus PVE can be treated successfully without cardiac surgery. Conversely, patients with major complicated PVE should preferentially undergo surgery. Predictors of mortality in patients with PVE included septic shock and perforce conservative treatment.

Section snippets

Methods

From June 2000 to June 2006, 80 patients >16 years of age were consecutively included if they met the modified Duke criteria for definite PVE.1 PVE included not only patients with mechanical prosthesis but also those with bioprosthetic valves. Patients underwent cardiac surgery according to predefined criteria for surgical intervention.2 All patients were treated according to the American Heart Association guidelines3 and were seen by the cardiologist, cardiac surgeon, and infectious diseases

Results

The man/woman ratio was 2.5/2. Thirty-nine percent of cases were of nosocomial origin. The most frequent type of prosthetic valve was mechanical (61%). Epidemiologic characteristics and presence of underlying conditions are presented in Table 1.

Biological prosthetic valves were significantly associated with early PVE, in particular 48% (13 of 27) of PVEs on biological valves included early PVE versus 16% (6 of 49) of PVEs on mechanical valves (p = 0.001); Two patients had early PVE on

Discussion

The present study is the first to analyze outcome in surgically versus deliberately conservatively treated PVE patients. This study suggests that there remains a role for watchful waiting after diagnosis and institution of antibiotics in patients with PVE and no evidence of major complications. Moreover, our findings support that patients with uncomplicated S. aureus PVE can be treated successfully without cardiac surgery. In our series, almost ½ of patients underwent cardiac surgery, mainly

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