Prosthetic valve endocarditis
Prosthetic valve endocarditis is infection of a prosthetic heart valve, classified as early or late by time from surgery, and it is more aggressive and harder to treat than native valve disease. It commonly causes perivalvular abscess and dehiscence, requires transesophageal echocardiography and prolonged antibiotics, and often needs surgery.
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What this article covers
- Overview
Definition: prosthetic valve endocarditis (PVE) is infective endocarditis involving a surgically or transcatheter-implanted prosthetic valve, classified as early (within a year, often perioperatively acquired) or late.
- Epidemiology
A serious complication after valve replacement, with cumulative lifetime risk.
- Risk factors
Any prosthetic valve (mechanical or bioprosthetic, surgical or transcatheter).
- Pathophysiology
Sewing-ring and perivalvular seeding: infection localizes at the prosthesis-annulus interface rather than only the leaflets.
- Clinical features
Fever and constitutional symptoms. A new prosthetic regurgitant (paravalvular) murmur and signs of heart failure.
- Differential diagnosis
Native valve endocarditis: infective endocarditis of a native valve, distinguished by the absence of prosthetic material and involvement of native leaflets on echocardiography (Bacterial infective endocarditis).
- Diagnosis
Establish with the modified Duke criteria, using transesophageal echocardiography and often additional imaging: the diagnostic basis is positive blood cultures with echocardiographic evidence of…
- Management
First-line, start prolonged targeted intravenous antibiotics after cultures: begin pathogen-directed therapy (empirically vancomycin 15 to 20 mg/kg IV every 8 to 12 hours plus gentamicin and, for…
- Complications
Perivalvular abscess, dehiscence, and paravalvular regurgitation.
- Prognosis
Worse than native valve endocarditis, with high mortality.
- Prevention
Antibiotic prophylaxis before high-risk dental procedures (prosthetic valves are high risk; amoxicillin 2 g PO 30 to 60 minutes before the procedure).
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Related articles
- Infective endocarditis
Infective endocarditis is microbial infection of the endocardium, usually a heart valve, producing vegetations that cause valve destruction, embolism, and systemic infection. Diagnosis uses the modified Duke criteria combining blood cultures and echocardiography, and treatment is prolonged targeted intravenous antibiotics with surgery for complications.
- Prosthetic valve thrombosis
Prosthetic valve thrombosis is thrombus on a prosthetic valve, most often a mechanical valve with inadequate anticoagulation, causing obstruction or embolism. It presents with heart failure, muffled prosthetic sounds, or embolic events, is confirmed by echocardiography and fluoroscopy, and is treated by surgery or fibrinolysis depending on severity.
- Aortic regurgitation
Aortic regurgitation is diastolic backflow of blood from the aorta into the left ventricle from valve or aortic root disease. Chronic disease causes volume overload with a wide pulse pressure and a decrescendo diastolic murmur, while acute severe regurgitation is a surgical emergency; severe symptomatic or decompensating disease is treated with valve replacement.
- Nonbacterial thrombotic endocarditis
Nonbacterial thrombotic endocarditis (marantic endocarditis) is sterile platelet-fibrin vegetations on cardiac valves associated with malignancy and autoimmune disease, notably antiphospholipid syndrome and lupus (Libman-Sacks). It rarely destroys valves but embolizes readily, so treatment is anticoagulation and management of the underlying disease.