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Potentially life-threatening emergency
Prosthetic valve endocarditis
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Potentially life-threatening emergency

Prosthetic valve endocarditis

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Contributors: Varda Singhal MD, Ryan Hoefen MD, PhD
Other Resources UpToDate PubMed

Synopsis

A life-threatening infection of a prosthetic heart valve resulting in prolonged bacteremia as well as formation of a vegetation on the valve. Usual signs and symptoms include fever, a new cardiac murmur, shortness of breath, and characteristic cutaneous lesions. Complications may include myocardial abscess formation, valvular regurgitation, and/or embolization.

The risk of developing prosthetic valve endocarditis (PVE) is greatest during the initial 3 months after surgery, remains high for 6 months, and then falls gradually. Infection generally occurs with equal frequency on aortic and mitral sites as well as on mechanical and bioprosthetic devices during the first postoperative year. Afterward, bioprosthetic valves have a higher risk of infection due to age-related alterations in the valves' surfaces.

PVE can be divided into early and late infection.
  • Early – Microorganisms reach the prosthesis by direct contamination intraoperatively or via hematogenous spread. Common organisms, in order of decreasing frequency, are Staphylococcus aureus and coagulase-negative staphylococci, gram-negative bacilli, and fungal organisms.
  • Late – Generally caused by the same pathogens as native valve infection. The usual organisms are streptococci, S. aureus, coagulase-negative staphylococci, and enterococci.
As with native valve endocarditis, the diagnosis of PVE is usually made or suspected based on Modified Duke Criteria, combining physical examination, blood culture, and echocardiographic data.

The mainstay of treatment is antibiotics that are started empirically and later tailored based on culture data. The usual choice for empiric therapy is vancomycin and gentamicin with either cefepime or a carbapenem. The common duration of antibiotic treatment is 6 weeks. Indications for surgery include persistent bacteremia or fever lasting more than 5-7 days despite appropriate antibiotic therapy, valve dysfunction causing heart failure, paravalvular abscess or fistulae, heart block, relapse after optimum medical therapy, and infection with highly resistant organisms like S. aureus, gram-negative rods, or fungi.

Codes

ICD10CM:
T82.6XXA – Infection and inflammatory reaction due to cardiac valve prosthesis, initial encounter

SNOMEDCT:
233853009 – Prosthetic valve endocarditis

Differential Diagnosis & Pitfalls

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Last Updated: 01/31/2017
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Potentially life-threatening emergency
Prosthetic valve endocarditis
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Prosthetic valve endocarditis : Fever, Heart murmur
Clinical image of Prosthetic valve endocarditis
Staphylococcus aureus prosthetic valve endocarditis.
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