Prosthetic Valve Endocarditis

More than 60,000 prosthetic heart valves are implanted in United States annually. Prosthetic valve endocarditis is classified as early (up to 60 days after valve replacement), intermediate (2 months to 12 months), and late (>12 months). IE is a rare complication occurring in 0.5% to 1% of cases per year, and its late occurrence is even less common [39]. In patients with prosthetic valves and nosocomial bacteremia, 43% may have IE [40]. This risk is similar for mechanical and bioprosthetic valves. In mechanical valves, infection is usually located at sewing ring, in bioprosthetic valves it can also involve the cusps, while in composite graft it may even affect distal anastomosis or coronary reimplantation site [41].

El-Ahdab et al. evaluated the incidence and outcome of IE in patients with prosthetic valves with S. aureus bacteremia [42]. The overall rate of definite IE was 51%. The incidence was not different between mechanical versus biopros-thetic valves, mitral versus aortic prostheses, and early (< 12 months after prosthetic valve implantation) versus late (>12 months after implantation) presentation. There was a higher incidence of definite endocarditis in patients with persistent fever and persistent bacteremia.

In prosthetic valves, the sensitivity of TTE is only 17% to 36% and for TEE is 82% to 96% [40]. TEE should be the test of choice in suspected prosthetic valve endocarditis, especially in the mitral position, because of its increased sensitivity for the detection of complications (abscesses, paravalvular leaks, dehiscence of the valves) and because of the limitation of TTE in the diagnosis (reverberations artifact from metallic structures). TTE should be repeated in high-risk patients for IE (persistent fever, persistent bac-teremia, unknown source of infection), if the initial study is negative [42].

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