Contemporary management of prosthetic valve endocarditis: principals and future outlook

Abstract

Infective endocarditis involving prosthetic valves accounts for 20% of all endocarditis cases. Rising in prevalence due to increasing placement of valvular prostheses, prosthetic valve endocarditis (PVE) is more difficult to diagnose by conventional methods, associated with more invasive infection and increased mortality. This report explores the existing literature in identifying a direct approach to the management of PVE; such as adjuncts to establishing a diagnosis (for instance positron emission tomography/computed tomography and radiolabeled leukocyte scintigraphy), the trends in specific pathogens associated with PVE and the recommended antimicrobials for each. The patterns of disease requiring surgical intervention are also highlighted and explored. In addition, a 5-year outlook offers consolidated knowledge on epidemiological trends of both culprit organisms and population subgroups suffering (and projected to suffer) from PVE.

Keywords:

• infective endocarditis
• management
• prosthetic valve endocarditis
• review
• valve

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Awareness of the increasing prevalence of prosthetic valve endocarditis (PVE) is important among medical colleagues wherein infectious pathology is suspected.

• The clinical diagnosis of endocarditis is typically made with Duke criteria. Diagnosis of PVE is no different; however, Duke sensitivity is impeded by difficulty in visualizing vegetations with transthoracic echocardiography. In patients with valvular prostheses, Duke criteria with transesophageal echocardiography is advised. Modalities such as positron emission tomography/computed tomography and radiolabeled leukocyte scintigraphy are useful tools in establishing a diagnosis.

• Identification of the infectious pathogen is central to the treatment of PVE. Given the yield of blood cultures is less than in native valve endocarditis, every effort should be taken to yield.

• The selection of antimicrobial agent(s) is determined by the susceptibilities of the culprit organism. These must be appropriate for the etiological organism and it is advised that therapy is guided by either the American Heart Association or the European Society of Cardiology guidelines.

• It is essential that every patient presenting with suspected PVE is promptly assessed for surgical candidacy. Those recommended to have surgery are patients exhibiting clinical heart failure or patients suffering embolic phenomena. If the heart failure is tolerated, surgery can be carried out expeditiously; however, if the patient’s heart failure is decompensated, surgery may need to be performed on an emergency basis.

Notes