Infective Endocarditis of Valve Prostheses Table 21 and

Infection of valve prostheses may manifest early after surgery or long after hospital discharge [43-46]. Both bacteria and fungal organisms are important causes of prosthetic IE [28]. Valvular bioprostheses have vegetation, cusp thrombi, destruction, erosion, and perforation similar to native valves (Figure 2.17). With infection of mechanical prostheses, the actual prosthesis usually remains intact and the infection is mainly in the sewing ring and surrounding tissues. The thrombi on a mechanical prosthesis or bioprosthesis may interfere with normal function, as the prosthesis may become dysfunctional with disc or cusp immobility (Figure 2.18) [9,27]. Peripheral emboli are not uncommon [43].

In any prosthesis, sewing ring and perivalvu-lar tissue infection is common, and the valve prosthesis may dehisce or become loose when the surrounding tissues develop necrosis [9,45]. Annular abscess and fistulas are much more common with prostheses, as compared to native valves. It is a disturbing and memorable experience to image a near totally dehisced valve prosthesis by echocardiography and for the surgeon to be able to remove such a valve prosthesis from the patient without much need for dissection. Sutures, pledgets, as well as the aortotomy site may become infected.

A large perivalvular leak results in severe perivalvular regurgitation and heart failure, but even a small perivalvular leak can be significant due to the development of severe hemolysis. Destruction of the adjacent tissues may lead to intracardiac fistulas, conduction system destruction and arrhythmias, and coronary artery inflammation and thrombosis [43]. The mortality of prosthetic IE remains high, with or without surgery, and perivalvular complications can develop despite surgery. Fungal infection of

Figure 2.18. Gross photograph of opened aortic root with a mechanical tilting disc prosthesis placed in the aortic valve position. A large amount of thrombus at the edge of the prosthesis is interfered with the disc movement.This is recurrent Aspergillus infection (same patient as Figures 2.10 and 2.14).There was recurrent stroke after valve replacement.

Figure 2.18. Gross photograph of opened aortic root with a mechanical tilting disc prosthesis placed in the aortic valve position. A large amount of thrombus at the edge of the prosthesis is interfered with the disc movement.This is recurrent Aspergillus infection (same patient as Figures 2.10 and 2.14).There was recurrent stroke after valve replacement.

a valve prosthesis is a surgical indication due to near total mortality without surgery [14,29,44].

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