Prosthetic Valve Endocarditis in the ICU: Prognostic Factors of Overall Survival in a Series of 122 Cases and Consequences for Treatment Decision

doi:10.1378/chest.108.3.688

Chest

Volume 108, Issue 3, September 1995, Pages 688-694

https://doi.org/10.1378/chest.108.3.688 Get rights and content

We carried out univariate and multivariate analysis of outcome among 122 patients with prosthetic valve endocarditis (PVE) admitted to our ICU between 1978 and 1992. The predominant pathogens were Staphylococcus aureus (33%), streptococci (20%), coagulase-negative staphylococci (12%), enterococci (10%), and Gram-negative bacilli (9%). At 4 months, overall survival was 66% (42 deaths). Staphylococcus aureus was the main predictor of death (75% vs 15% with other pathogens). In S aureus PVE, multivariate analysis identified the following predictors of death: prothrombin time <30% (relative risk [RR]: 8.3), concomitant mediastinitis (RR: 4.9), heart failure (RR: 4.4), and septic shock (RR: 2.6). In PVE due to other pathogens, prothrombin time <30% (RR: 32.26), renal failure (RR: 7.31), and heart failure (RR: 6.07) were associated with death. In S aureus PVE, survival was higher in patients who received medical-surgical therapy than in those who received medical therapy alone (9/20 [45%] vs 0/20) (p<0.01). In PVE due to other pathogens, there was no difference in survival between patients who underwent prosthesis replacement (89%) and those who received only medical treatment (81%). Among the 65 patients who underwent heart surgery, the mortality rate and incidence of postoperative paravalvular leakage did not correlate with positive prosthesis cultures. We conclude that non-S aureus and uncomplicated PVE may be managed without valve replacement but that prompt surgical intervention should be required in all other situations.

Section snippets

METHODS

The 122 studied patients were all admitted to our ICU, whereas during the same time period, other patients not as ill were admitted to the wards.

RESULTS

Prosthetic valve endocarditis was diagnosed in 122 patients admitted to our ICU between February 1978 and June 1992. They comprised 88 men and 34 women, with a mean age of 45 ± 17 years. The position of the prosthetic valve was aortic in 55 cases, mitral in 32, and both aortic and mitral in 27. Eight patients with aortic and/or mitral prosthesis also had tricuspid prosthesis. Prosthetic valve endocarditis was certain in 96 patients and probable in 26. Seventy patients had 82 mechanical valves

DISCUSSION

Infection of intracardiac prostheses is a serious, often life-threatening complication of valve replacement surgery. The mortality rate within 120 days of hospital admission was 34%, a figure comparable to the overall PVE-related mortality rate of 42% estimated from eight previous series totaling 565 patients.⁴^,⁸^,⁹^,¹¹^,¹³^,¹⁹^,²⁰ In a recent prospective study involving 74 cases of PVE, the mortality rates were 41%, 46%, and 47% at 2, 6, and 12 months, respectively.²¹ A number of clinical findings

ACKNOWLEDGMENTS

The authors are indebted to Dr. David Young for assistance in the preparation of the manuscript.

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