Chest
Volume 101, Issue 1, January 1992, Pages 37-41
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Clinical Investigations
Late Prosthetic Valve Endocarditis: Immediate and Long-term Prognosis

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From 1975 to 1989, 307 consecutive episodes of infective endocarditis were diagnosed in our hospital. Of those, 35 were cases of late prosthetic valve endocarditis, defined as those occurring after 12 months of valvular replacement. Blood cultures grew streptococci in 15 patients (43 percent), staphylococci in seven (20 percent), enterococci in five (14 percent), Gram-negative bacilli of HACEK group in four (11.5 percent), and Candida in one. Blood cultures were negative in three cases (prosthetic infection was confirmed at surgery). Heart failure due to prosthetic dysfunction occurred in seven patients (20 percent) and emboli in 12 (34 percent). Early valvular replacement was performed in six patients (17 percent). Complications and mortality were dependent on the infective agent. Overall mortality was 23 percent, no death occurred from streptococcal infection, whereas mortality with endocarditis by organisms of the HACEK group and Staphylococcus was 50 percent and 43 percent, respectively. During a mean follow-up of five years, 11 patients (those with prosthetic leaks diagnosed during the active infection and patients with biologic prostheses) required surgery. There was one relapse in a patient with staphylococcal endocarditis and one recurrence, six years after the initial episode. We conclude that immediate prognosis of late prosthetic valve endocarditis depends on the infective agent. Although the immediate prognosis of streptococcal infections is good, the need for early reoperation during follow-up due to progressive perivalvular leak is high. Also, it appears that deterioration of bioprostheses proceeds swiftly after the cure of infection.

(Chest 1992; 101:37-41)

Section snippets

PATIENTS AND METHODS

From January 1975 to December 1989, 307 consecutive episodes of infectious endocarditis were diagnosed in our hospital. Of those, 35 cases (11.4 percent) developed 12 months or more after valve replacement. These cases were considered as having late prosthetic valve endocarditis. The diagnosis of prosthetic endocarditis was made when two of the following criteria were present: (1) clinical findings consistent with infective endocarditis; (2) two or more blood cultures positive for the same

RESULTS

The series consists of 35 consecutive episodes of late prosthetic valve endocarditis diagnosed in 34 patients. One patient suffered from two episodes of endocarditis with an interval of six years. There were 22 (65 percent) male and 12 (35 percent) female patients. The mean age was 44 years, ranging from 18 to 71 years. There were 16 patients with a mitral prostheses, 16 with an aortic prosthesis, and five carried two prosthesis (four in mitral and aortic position and one in mitral and

DISCUSSION

Prosthetic valve endocarditis is a serious complication of cardiac valve replacement. It was classically divided into early and late cases referring to nosocomial, surgery-acquired cases, and those with a pathogenesis similar to native valve endocarditis. We have used a 12-month period to define early and late cases because we believe, in agreement with other authors,6 that in this way, it is unlikely that early cases are included as late, as could be the case using a two-month dividing line.

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