Prosthetic Valve Endocarditis
2005; Elsevier BV; Volume: 80; Issue: 3 Linguagem: Inglês
10.1016/j.athoracsur.2004.11.001
ISSN1552-6259
AutoresBalakrishnan Mahesh, Gianni D. Angelini, Massimo Caputo, Xu Yu Jin, Alan J. Bryan,
Tópico(s)Infectious Aortic and Vascular Conditions
ResumoProsthetic valve endocarditis is a catastrophic complication of cardiac valve replacement, associated with high mortality rates. Medical treatment is effective in a few instances of endocarditis involving the leaflets alone in bioprostheses. However, accurate diagnosis, better myocardial protection, and improved surgical strategies have led to better survival in patients undergoing surgery after failed conservative therapy. This comprehensive review addresses various issues involved in the management of this complication. Prosthetic valve endocarditis is a catastrophic complication of cardiac valve replacement, associated with high mortality rates. Medical treatment is effective in a few instances of endocarditis involving the leaflets alone in bioprostheses. However, accurate diagnosis, better myocardial protection, and improved surgical strategies have led to better survival in patients undergoing surgery after failed conservative therapy. This comprehensive review addresses various issues involved in the management of this complication. Prosthetic valve endocarditis (PVE) is a catastrophic complication of valve replacement [1Dossche K.M. Defauw J.J. Ernst S.M. Craenen T.W. De Jongh B.M. de la Riviere A.B. Allograft aortic root replacement in prosthetic aortic valve endocarditis a review of 32 patients.Ann Thorac Surg. 1997; 63: 1644-1649Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar, 2Vlessis A.A. Khaki A. Grunkemeier G.L. Li H.H. Starr A. Risk, diagnosis and management of prosthetic valve endocarditis a review.J Heart Valve Dis. 1997; 6: 443-465PubMed Google Scholar, 3d'Udekem Y. David T.E. Feindel C.M. Armstrong S. Sun Z. Long-term results of operation for paravalvular abscess.Ann Thorac Surg. 1996; 62: 48-53Abstract Full Text PDF PubMed Scopus (133) Google Scholar, 4Lytle B.W. Surgical treatment of prosthetic valve endocarditis.Semin Thorac Cardiovasc Surg. 1995; 7: 13-19PubMed Google Scholar, 5Guerra J.M. Tornos M.P. Permanyer-Miralda G. Almirante B. Murtra M. Soler-Soler J. Long term results of mechanical prostheses for treatment of active infective endocarditis.Heart. 2001; 86: 63-68Crossref PubMed Scopus (47) Google Scholar]. Prosthetic valve endocarditis is defined as infection occurring in a prosthetic heart valve with overall incidence of 0.32 to 1.2% per patient year and cumulative risk of 5% at 10 years. In the past, surgery for PVE was associated with a mortality of 25%–60% [6Edwards M.B. Ratnatunga C.P. Dore C.J. Taylor K.M. Thirty-day mortality and long-term survival following surgery for prosthetic endocarditis a study from the UK heart valve registry.Eur J Cardiothorac Surg. 1998; 14: 156-164Crossref PubMed Scopus (79) Google Scholar, 7Renzulli A. Carozza A. Romano G. De Feo M. Della C.A. Gregorio R. Cotrufo M. Recurrent infective endocarditis a multivariate analysis of 21 years of experience.Ann Thorac Surg. 2001; 72: 39-43Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar, 8McGiffin D.C. Kirklin J.K. The impact of aortic valve homografts on the treatment of aortic prosthetic valve endocarditis.Semin Thorac Cardiovasc Surg. 1995; 7: 25-31PubMed Google Scholar]. Earlier diagnosis, better myocardial protection, and improved surgical approaches have led to better survival results in PVE [4Lytle B.W. Surgical treatment of prosthetic valve endocarditis.Semin Thorac Cardiovasc Surg. 1995; 7: 13-19PubMed Google Scholar, 7Renzulli A. Carozza A. Romano G. De Feo M. Della C.A. Gregorio R. Cotrufo M. Recurrent infective endocarditis a multivariate analysis of 21 years of experience.Ann Thorac Surg. 2001; 72: 39-43Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar]. This review will analyze the pathophysiology, clinical features, and therapeutic options in PVE. A thorough search was made on Medline, National Library of Medicine, using keywords—prosthetic valve endocarditis, endocarditis, stentless valves, Ross procedure, paraprosthetic abscesses, Silzone valve, and prosthetic valves. References were selected if they were dealing with greater than 15 patients with PVE. If there were many references by the same group, the most recent and relevant ones were selected. Smaller series were selected if they involved stentless valves or newer prostheses. Prosthetic valve endocarditis is defined as early if occurring within 12 months of valve replacement and late if greater than 12 months have elapsed [1Dossche K.M. Defauw J.J. Ernst S.M. Craenen T.W. De Jongh B.M. de la Riviere A.B. Allograft aortic root replacement in prosthetic aortic valve endocarditis a review of 32 patients.Ann Thorac Surg. 1997; 63: 1644-1649Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar, 4Lytle B.W. Surgical treatment of prosthetic valve endocarditis.Semin Thorac Cardiovasc Surg. 1995; 7: 13-19PubMed Google Scholar, 5Guerra J.M. Tornos M.P. Permanyer-Miralda G. Almirante B. Murtra M. Soler-Soler J. Long term results of mechanical prostheses for treatment of active infective endocarditis.Heart. 2001; 86: 63-68Crossref PubMed Scopus (47) Google Scholar, 9Petrou M. Wong K. Albertucci M. Brecker S.J. Yacoub M.H. Evaluation of unstented aortic homografts for the treatment of prosthetic aortic valve endocarditis.Circulation. 1994; 90: II198-II204PubMed Google Scholar, 10Muehrcke D.D. Lytle B.W. Cosgrove III, D.M. Surgical and long-term antifungal therapy for fungal prosthetic valve endocarditis.Ann Thorac Surg. 1995; 60: 538-543Abstract Full Text PDF PubMed Scopus (96) Google Scholar, 11Delay D. Pellerin M. Carrier M. et al.Immediate and long-term results of valve replacement for native and prosthetic valve endocarditis.Ann Thorac Surg. 2000; 70: 1219-1223Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar]. Most cases are caused by Staphylococcus epidermidis and aureus, followed by Streptococcus viridans [8McGiffin D.C. Kirklin J.K. The impact of aortic valve homografts on the treatment of aortic prosthetic valve endocarditis.Semin Thorac Cardiovasc Surg. 1995; 7: 25-31PubMed Google Scholar, 12Vongpatanasin W. Hillis L.D. Lange R.A. Prosthetic heart valves.N Engl J Med. 1996; 335: 407-416Crossref PubMed Scopus (631) Google Scholar, 13Hyde J.A. Darouiche R.O. Costerton J.W. Strategies for prophylaxis against prosthetic valve endocarditis a review article.J Heart Valve Dis. 1998; 7: 316-326PubMed Google Scholar]; early PVE is often due to methicillin-resistant Staphylococcus epidermidis, gram-negative bacilli, fungi, and other HACEK-group organisms (Haemophilus, Actinobacillus, Cardiobacterium, Eikinella, Kingella), suggesting nosocomial infection [1Dossche K.M. Defauw J.J. Ernst S.M. Craenen T.W. De Jongh B.M. de la Riviere A.B. Allograft aortic root replacement in prosthetic aortic valve endocarditis a review of 32 patients.Ann Thorac Surg. 1997; 63: 1644-1649Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar, 14Piper C. Korfer R. Horstkotte D. Prosthetic valve endocarditis.Heart. 2001; 85: 590-593Crossref PubMed Google Scholar]. Common sources of bacteremia include wound infections, intravascular catheter infections, urinary-tract infections, and pneumonia [2Vlessis A.A. Khaki A. Grunkemeier G.L. Li H.H. Starr A. Risk, diagnosis and management of prosthetic valve endocarditis a review.J Heart Valve Dis. 1997; 6: 443-465PubMed Google Scholar, 4Lytle B.W. Surgical treatment of prosthetic valve endocarditis.Semin Thorac Cardiovasc Surg. 1995; 7: 13-19PubMed Google Scholar, 13Hyde J.A. Darouiche R.O. Costerton J.W. Strategies for prophylaxis against prosthetic valve endocarditis a review article.J Heart Valve Dis. 1998; 7: 316-326PubMed Google Scholar, 15Fang G. Keys T.F. Gentry L.O. et al.Prosthetic valve endocarditis resulting from nosocomial bacteremia. A prospective, multicenter study.Ann Intern Med. 1993; 119: 560-567Crossref PubMed Google Scholar]. Infrequent, potentially fatal pathogens include fungi and mycoplasma; fungal PVE mandates surgery and long-term antifungal treatment and is associated with worse prognosis [10Muehrcke D.D. Lytle B.W. Cosgrove III, D.M. Surgical and long-term antifungal therapy for fungal prosthetic valve endocarditis.Ann Thorac Surg. 1995; 60: 538-543Abstract Full Text PDF PubMed Scopus (96) Google Scholar, 16Sett S.S. Hudon M.P. Jamieson W.R. Chow A.W. Prosthetic valve endocarditis. Experience with porcine bioprostheses.J Thorac Cardiovasc Surg. 1993; 105: 428-434PubMed Google Scholar], while mycoplasma can be treated very effectively by doxycycline alone [17Fenollar F. Gauduchon V. Casalta J.P. Lepidi H. Vandenesch F. Raoult D. Mycoplasma endocarditis two case reports and a review.Clin Infect Dis. 2004; 38: e21-e24Crossref PubMed Scopus (44) Google Scholar]. Late PVE occurs due to bacteremia from skin, orodental and abdominal infections, and invasive medical-dental procedures and therefore Streptococcus viridans and Staphylococcus epidermidis are common pathogens [2Vlessis A.A. Khaki A. Grunkemeier G.L. Li H.H. Starr A. Risk, diagnosis and management of prosthetic valve endocarditis a review.J Heart Valve Dis. 1997; 6: 443-465PubMed Google Scholar, 13Hyde J.A. Darouiche R.O. Costerton J.W. Strategies for prophylaxis against prosthetic valve endocarditis a review article.J Heart Valve Dis. 1998; 7: 316-326PubMed Google Scholar]. Important factors in the pathogenesis include type of prosthesis, previous native valve endocarditis, male gender, and long cardiopulmonary bypass (CPB) time [13Hyde J.A. Darouiche R.O. Costerton J.W. Strategies for prophylaxis against prosthetic valve endocarditis a review article.J Heart Valve Dis. 1998; 7: 316-326PubMed Google Scholar]. Early PVE rarely remains restricted to leaflets alone; frequently it involves the junction of the sewing ring and annulus, leading to valve dehiscence and paravalvular abscesses, which predispose to paraprosthetic leak and fistulization into other cardiac chambers or the pericardium [2Vlessis A.A. Khaki A. Grunkemeier G.L. Li H.H. Starr A. Risk, diagnosis and management of prosthetic valve endocarditis a review.J Heart Valve Dis. 1997; 6: 443-465PubMed Google Scholar, 4Lytle B.W. Surgical treatment of prosthetic valve endocarditis.Semin Thorac Cardiovasc Surg. 1995; 7: 13-19PubMed Google Scholar, 18Hagl C. Galla J.D. Lansman S.L. et al.Replacing the ascending aorta and aortic valve for acute prosthetic valve endocarditis is using prosthetic material contraindicated?.Ann Thorac Surg. 2002; 74: S1781-S1785Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar], invariably necessitating replacement irrespective of the type of prosthesis [19Moon M.R. Miller D.C. Moore K.A. et al.Treatment of endocarditis with valve replacement the question of tissue versus mechanical prosthesis.Ann Thorac Surg. 2001; 71: 1164-1171Abstract Full Text Full Text PDF PubMed Scopus (168) Google Scholar], and associated with worse prognosis than late PVE [13Hyde J.A. Darouiche R.O. Costerton J.W. Strategies for prophylaxis against prosthetic valve endocarditis a review article.J Heart Valve Dis. 1998; 7: 316-326PubMed Google Scholar]. Prostheses from metal and pyrolyte do not allow adherence of microorganisms to leaflets as long as they are free of thrombotic material [14Piper C. Korfer R. Horstkotte D. Prosthetic valve endocarditis.Heart. 2001; 85: 590-593Crossref PubMed Google Scholar]. Herein lies the importance of biofilms produced by bacteria, which enable them to adhere to surfaces of valves in the presence of high blood flow, protecting them from antibiotics [13Hyde J.A. Darouiche R.O. Costerton J.W. Strategies for prophylaxis against prosthetic valve endocarditis a review article.J Heart Valve Dis. 1998; 7: 316-326PubMed Google Scholar, 14Piper C. Korfer R. Horstkotte D. Prosthetic valve endocarditis.Heart. 2001; 85: 590-593Crossref PubMed Google Scholar]. Infections in mechanical valves generally involve the sewing ring or adherent thrombi, leading to paraprosthetic leaks, ring abscesses, and invasive infection, necessitating operative intervention [8McGiffin D.C. Kirklin J.K. The impact of aortic valve homografts on the treatment of aortic prosthetic valve endocarditis.Semin Thorac Cardiovasc Surg. 1995; 7: 25-31PubMed Google Scholar, 13Hyde J.A. Darouiche R.O. Costerton J.W. Strategies for prophylaxis against prosthetic valve endocarditis a review article.J Heart Valve Dis. 1998; 7: 316-326PubMed Google Scholar, 14Piper C. Korfer R. Horstkotte D. Prosthetic valve endocarditis.Heart. 2001; 85: 590-593Crossref PubMed Google Scholar, 16Sett S.S. Hudon M.P. Jamieson W.R. Chow A.W. Prosthetic valve endocarditis. Experience with porcine bioprostheses.J Thorac Cardiovasc Surg. 1993; 105: 428-434PubMed Google Scholar]. Incidence of myocardial and paravalvular abscesses in mechanical PVE is estimated to be 38% and 63%, respectively [8McGiffin D.C. Kirklin J.K. The impact of aortic valve homografts on the treatment of aortic prosthetic valve endocarditis.Semin Thorac Cardiovasc Surg. 1995; 7: 25-31PubMed Google Scholar]. Staphylococci are the most common organisms causing paravalvular abscesses; these are extremely virulent, often requiring surgical treatment and associated with higher mortality rates [3d'Udekem Y. David T.E. Feindel C.M. Armstrong S. Sun Z. Long-term results of operation for paravalvular abscess.Ann Thorac Surg. 1996; 62: 48-53Abstract Full Text PDF PubMed Scopus (133) Google Scholar]. Bioprostheses are less susceptible to early infection, which is often restricted to the leaflets [16Sett S.S. Hudon M.P. Jamieson W.R. Chow A.W. Prosthetic valve endocarditis. Experience with porcine bioprostheses.J Thorac Cardiovasc Surg. 1993; 105: 428-434PubMed Google Scholar], making cure with antibiotics more likely, but increasing the chances of late failure due to degeneration of the cusps. This could also predispose to late infection due to implantation of organisms at sites of leaflet degeneration [2Vlessis A.A. Khaki A. Grunkemeier G.L. Li H.H. Starr A. Risk, diagnosis and management of prosthetic valve endocarditis a review.J Heart Valve Dis. 1997; 6: 443-465PubMed Google Scholar, 12Vongpatanasin W. Hillis L.D. Lange R.A. Prosthetic heart valves.N Engl J Med. 1996; 335: 407-416Crossref PubMed Scopus (631) Google Scholar, 19Moon M.R. Miller D.C. Moore K.A. et al.Treatment of endocarditis with valve replacement the question of tissue versus mechanical prosthesis.Ann Thorac Surg. 2001; 71: 1164-1171Abstract Full Text Full Text PDF PubMed Scopus (168) Google Scholar, 20Haydock D. Barratt-Boyes B. Macedo T. Kirklin J.W. Blackstone E. Aortic valve replacement for active infectious endocarditis in 108 patients. A comparison of freehand allograft valves with mechanical prostheses and bioprostheses.J Thorac Cardiovasc Surg. 1992; 103: 130-139PubMed Google Scholar]. The risk of sewing-ring infection is less, but once involved the pathogenesis is the same as for mechanical prostheses [14Piper C. Korfer R. Horstkotte D. Prosthetic valve endocarditis.Heart. 2001; 85: 590-593Crossref PubMed Google Scholar], and may form annular abscesses [16Sett S.S. Hudon M.P. Jamieson W.R. Chow A.W. Prosthetic valve endocarditis. Experience with porcine bioprostheses.J Thorac Cardiovasc Surg. 1993; 105: 428-434PubMed Google Scholar]. Late PVE is more likely than early PVE to be restricted to the valve leaflets alone [4Lytle B.W. Surgical treatment of prosthetic valve endocarditis.Semin Thorac Cardiovasc Surg. 1995; 7: 13-19PubMed Google Scholar]. Even in the absence of previous PVE, areas of degenerative changes in biological valves predispose to implantation of organisms. Common clinical presentations include persistent fever after valve replacement, profound anorexia, new (changing) murmur, heart block, congestive heart failure (CHF), and embolic events. Myocardial infarction (MI) due to emboli and sudden death from disruption of the valve are more dramatic events [2Vlessis A.A. Khaki A. Grunkemeier G.L. Li H.H. Starr A. Risk, diagnosis and management of prosthetic valve endocarditis a review.J Heart Valve Dis. 1997; 6: 443-465PubMed Google Scholar, 4Lytle B.W. Surgical treatment of prosthetic valve endocarditis.Semin Thorac Cardiovasc Surg. 1995; 7: 13-19PubMed Google Scholar, 7Renzulli A. Carozza A. Romano G. De Feo M. Della C.A. Gregorio R. Cotrufo M. Recurrent infective endocarditis a multivariate analysis of 21 years of experience.Ann Thorac Surg. 2001; 72: 39-43Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar, 16Sett S.S. Hudon M.P. Jamieson W.R. Chow A.W. Prosthetic valve endocarditis. Experience with porcine bioprostheses.J Thorac Cardiovasc Surg. 1993; 105: 428-434PubMed Google Scholar]. Diagnosis rests on multiple blood cultures drawn before commencement of antibiotics [2Vlessis A.A. Khaki A. Grunkemeier G.L. Li H.H. Starr A. Risk, diagnosis and management of prosthetic valve endocarditis a review.J Heart Valve Dis. 1997; 6: 443-465PubMed Google Scholar, 4Lytle B.W. Surgical treatment of prosthetic valve endocarditis.Semin Thorac Cardiovasc Surg. 1995; 7: 13-19PubMed Google Scholar, 7Renzulli A. Carozza A. Romano G. De Feo M. Della C.A. Gregorio R. Cotrufo M. Recurrent infective endocarditis a multivariate analysis of 21 years of experience.Ann Thorac Surg. 2001; 72: 39-43Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar, 16Sett S.S. Hudon M.P. Jamieson W.R. Chow A.W. Prosthetic valve endocarditis. Experience with porcine bioprostheses.J Thorac Cardiovasc Surg. 1993; 105: 428-434PubMed Google Scholar]. Blood cultures are frequently negative if taken after commencement of antibiotics. Persistent bacteremia with no other indication of endocarditis is a strong predictor of the future development of endocarditis [15Fang G. Keys T.F. Gentry L.O. et al.Prosthetic valve endocarditis resulting from nosocomial bacteremia. A prospective, multicenter study.Ann Intern Med. 1993; 119: 560-567Crossref PubMed Google Scholar]. Echocardiography [21Bonow R.O. Carabello B. de Leon Jr, A.C. et al.Guidelines for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Valvular Heart Disease).Circulation. 1998; 98: 1949-1984Crossref PubMed Scopus (826) Google Scholar, 22Lengyel M. The impact of transesophageal echocardiography on the management of prosthetic valve endocarditis experience of 31 cases and review of the literature.J Heart Valve Dis. 1997; 6: 204-211PubMed Google Scholar] should be performed in all cases of suspected PVE, to characterize valvular hemodynamics and detect vegetations, abscesses, shunts, etc [21Bonow R.O. Carabello B. de Leon Jr, A.C. et al.Guidelines for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Valvular Heart Disease).Circulation. 1998; 98: 1949-1984Crossref PubMed Scopus (826) Google Scholar]. This may be used to assess the sewing ring stability and leaflet motion of bioprosthetic valves, but in mechanical PVE, intense reverberations from the valve limit its ability to detect vegetations, especially from the mitral valve [12Vongpatanasin W. Hillis L.D. Lange R.A. Prosthetic heart valves.N Engl J Med. 1996; 335: 407-416Crossref PubMed Scopus (631) Google Scholar]. Transesophageal echocardiography (TEE) has made a major impact on early recognition of PVE, with a twofold to threefold higher sensitivity compared to transthoracic echocardiography (TTE) [3d'Udekem Y. David T.E. Feindel C.M. Armstrong S. Sun Z. Long-term results of operation for paravalvular abscess.Ann Thorac Surg. 1996; 62: 48-53Abstract Full Text PDF PubMed Scopus (133) Google Scholar]. Transesophageal echocardiography is particularly sensitive in detecting paravalvular abscesses and valvular dysfunction in the form of stenosis, regurgitation, and paravalvular leak, and vegetations as small as 1 to 2 mm in size, particularly in relation to mitral prostheses [12Vongpatanasin W. Hillis L.D. Lange R.A. Prosthetic heart valves.N Engl J Med. 1996; 335: 407-416Crossref PubMed Scopus (631) Google Scholar, 14Piper C. Korfer R. Horstkotte D. Prosthetic valve endocarditis.Heart. 2001; 85: 590-593Crossref PubMed Google Scholar]. Sensitivity and specificity of TEE approach 100% and 83%, respectively, compared to morphologic findings [22Lengyel M. The impact of transesophageal echocardiography on the management of prosthetic valve endocarditis experience of 31 cases and review of the literature.J Heart Valve Dis. 1997; 6: 204-211PubMed Google Scholar]. However, TEE may not be sufficient to assess the anterior aspect of an aortic prosthesis, especially in the presence of a mitral prosthesis, and thus both TTE and TEE may be needed for complete assessment [12Vongpatanasin W. Hillis L.D. Lange R.A. Prosthetic heart valves.N Engl J Med. 1996; 335: 407-416Crossref PubMed Scopus (631) Google Scholar]. Negative echocardiography does not exclude PVE. Leukocyte scans have been used to detect abscesses, with limited success [14Piper C. Korfer R. Horstkotte D. Prosthetic valve endocarditis.Heart. 2001; 85: 590-593Crossref PubMed Google Scholar]. Magnetic resonance imaging may be performed safely in PVE, and is useful for identifying infective periprosthetic tissue signals, even before the development of blood flow abnormalities such as periprosthetic leakage [4Lytle B.W. Surgical treatment of prosthetic valve endocarditis.Semin Thorac Cardiovasc Surg. 1995; 7: 13-19PubMed Google Scholar], and distinguishing between valvular and paravalvular regurgitation [12Vongpatanasin W. Hillis L.D. Lange R.A. Prosthetic heart valves.N Engl J Med. 1996; 335: 407-416Crossref PubMed Scopus (631) Google Scholar]. Coronary angiography to look for coexistent coronary artery disease may be needed [23Jault F. Gandjbakhch I. Chastre J.C. et al.Prosthetic valve endocarditis with ring abscesses. Surgical management and long-term results.J Thorac Cardiovasc Surg. 1993; 105: 1106-1113PubMed Google Scholar], but may be hazardous in the presence of vegetations [20Haydock D. Barratt-Boyes B. Macedo T. Kirklin J.W. Blackstone E. Aortic valve replacement for active infectious endocarditis in 108 patients. A comparison of freehand allograft valves with mechanical prostheses and bioprostheses.J Thorac Cardiovasc Surg. 1992; 103: 130-139PubMed Google Scholar]. Broad-spectrum antibiotics started on suspicion of PVE, tailored subsequently to suit the sensitivity of the organisms, constitute the first line of treatment, and may reduce systemic embolization by shrinking existing vegetations and preventing formation of new ones [2Vlessis A.A. Khaki A. Grunkemeier G.L. Li H.H. Starr A. Risk, diagnosis and management of prosthetic valve endocarditis a review.J Heart Valve Dis. 1997; 6: 443-465PubMed Google Scholar]. In cases of culture negative, presumed bacterial endocarditis, broad-spectrum antibiotics need to be continued for 6 weeks [13Hyde J.A. Darouiche R.O. Costerton J.W. Strategies for prophylaxis against prosthetic valve endocarditis a review article.J Heart Valve Dis. 1998; 7: 316-326PubMed Google Scholar, 21Bonow R.O. Carabello B. de Leon Jr, A.C. et al.Guidelines for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Valvular Heart Disease).Circulation. 1998; 98: 1949-1984Crossref PubMed Scopus (826) Google Scholar]. Culture negative PVE may be due to fungi (candida/aspergillus) [21Bonow R.O. Carabello B. de Leon Jr, A.C. et al.Guidelines for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Valvular Heart Disease).Circulation. 1998; 98: 1949-1984Crossref PubMed Scopus (826) Google Scholar], Mycoplasma, and Ureaplasma. The latter are only occasionally detected by serology, but more often by polymerase chain reaction on the explanted valve. Specific treatment with doxycycline for 4 weeks results in complete cure [17Fenollar F. Gauduchon V. Casalta J.P. Lepidi H. Vandenesch F. Raoult D. Mycoplasma endocarditis two case reports and a review.Clin Infect Dis. 2004; 38: e21-e24Crossref PubMed Scopus (44) Google Scholar]. Patients must be monitored closely for progressive CHF, worsening conduction abnormalities, and complications such as annular abscesses, fistulas, or paravalvular leaks [1Dossche K.M. Defauw J.J. Ernst S.M. Craenen T.W. De Jongh B.M. de la Riviere A.B. Allograft aortic root replacement in prosthetic aortic valve endocarditis a review of 32 patients.Ann Thorac Surg. 1997; 63: 1644-1649Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar, 3d'Udekem Y. David T.E. Feindel C.M. Armstrong S. Sun Z. Long-term results of operation for paravalvular abscess.Ann Thorac Surg. 1996; 62: 48-53Abstract Full Text PDF PubMed Scopus (133) Google Scholar, 16Sett S.S. Hudon M.P. Jamieson W.R. Chow A.W. Prosthetic valve endocarditis. Experience with porcine bioprostheses.J Thorac Cardiovasc Surg. 1993; 105: 428-434PubMed Google Scholar, 24Ivert T.S. Dismukes W.E. Cobbs C.G. Blackstone E.H. Kirklin J.W. Bergdahl L.A. Prosthetic valve endocarditis.Circulation. 1984; 69: 223-232Crossref PubMed Scopus (241) Google Scholar, 25Calderwood S.B. Swinski L.A. Karchmer A.W. Waternaux C.M. Buckley M.J. Prosthetic valve endocarditis. Analysis of factors affecting outcome of therapy.J Thorac Cardiovasc Surg. 1986; 92: 776-783PubMed Google Scholar]. In these situations, medical therapy alone is associated with high mortality, thus making surgery mandatory [15Fang G. Keys T.F. Gentry L.O. et al.Prosthetic valve endocarditis resulting from nosocomial bacteremia. A prospective, multicenter study.Ann Intern Med. 1993; 119: 560-567Crossref PubMed Google Scholar, 24Ivert T.S. Dismukes W.E. Cobbs C.G. Blackstone E.H. Kirklin J.W. Bergdahl L.A. Prosthetic valve endocarditis.Circulation. 1984; 69: 223-232Crossref PubMed Scopus (241) Google Scholar, 26Alexiou C. Langley S.M. Stafford H. Haw M.P. Livesey S.A. Monro J.L. Surgical treatment of infective mitral valve endocarditis predictors of early and late outcome.J Heart Valve Dis. 2000; 9: 327-334PubMed Google Scholar]. Surgery provides material for isolation of the organism, and some groups have used the Histoplasma capsulatum Accuprobe in sonication of explanted valves for rapidly arriving at a diagnosis [27Chemaly R.F. Tomford J.W. Hall G.S. Sholtis M. Chua J.D. Procop G.W. Rapid diagnosis of Histoplasma capsulatum endocarditis using the AccuProbe on an excised valve.J Clin Microbiol. 2001; 39: 2640-2641Crossref PubMed Scopus (28) Google Scholar]. A cerebral embolic event is associated with a higher operative mortality due to systemic heparinization and hypotension associated with CPB, which may cause worsening of cerebral edema or conversion of an ischemic into a hemorrhagic stroke [28Maruyama M. Kuriyama Y. Sawada T. Yamaguchi T. Fujita T. Omae T. Brain damage after open heart surgery in patients with acute cardioembolic stroke.Stroke. 1989; 20: 1305-1310Crossref PubMed Scopus (64) Google Scholar] (Table 1). Maruyama and colleagues [28Maruyama M. Kuriyama Y. Sawada T. Yamaguchi T. Fujita T. Omae T. Brain damage after open heart surgery in patients with acute cardioembolic stroke.Stroke. 1989; 20: 1305-1310Crossref PubMed Scopus (64) Google Scholar] have demonstrated a significantly worse outcome with cardiac surgery in patients with cerebral emboli due to vegetations, mainly due to infective vascular injury at the site of the embolus; this leads to conversion of an ischemic into a hemorrhagic stroke due to systemic heparinization for CPB. Surgery in the setting of stroke becomes imperative in cases of recurrent thromboembolism, persistent vegetations, and hemodynamic instability [28Maruyama M. Kuriyama Y. Sawada T. Yamaguchi T. Fujita T. Omae T. Brain damage after open heart surgery in patients with acute cardioembolic stroke.Stroke. 1989; 20: 1305-1310Crossref PubMed Scopus (64) Google Scholar, 29Vahedi K. Amarenco P. Cardiac causes of stroke.Curr Treat Options Neurol. 2000; 2: 305-318Crossref PubMed Google Scholar].Table 1Indications for Surgical Intervention•Severe congestive heart failure secondary to valvular dysfunction not responding to inotropic support and afterload reduction•Worsening cardiac, renal, or pulmonary function after initial improvement or stabilization•Persistent bacteremia and sepsis despite one week of antibiotic therapy•Embolization despite antibiotic therapy or large vegetations demonstrated on echocardiography, with a significant risk of embolization•Progression of intracardiac or perivalvular pathology identified by echocardiogram or suggested by new or worsening conduction abnormalities•Significant prosthetic valvular dysfunction or dehiscence or other evidence of sewing ring–native annulus infection•Annular abscesses, paravalvular leak, sinus, or aortic true or false aneurysm•Fungal or brucella PVE or late PVE from Staphyloccoccus aureus•Infection with gram negative organisms or organisms with poor response to antibiotics•Early PVE•Myocardial invasion signs such as new onset conduction abnormalities or atrioventricular block or echocardiogram showing abscesses•Valve obstruction with vegetationsData from references 1Dossche K.M. Defauw J.J. Ernst S.M. Craenen T.W. De Jongh B.M. de la Riviere A.B. Allograft aortic root replacement in prosthetic aortic valve endocarditis a review of 32 patients.Ann Thorac Surg. 1997; 63: 1644-1649Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar, 3d'Udekem Y. David T.E. Feindel C.M. Armstrong S. Sun Z. Long-term results of op
Referência(s)