Epidemiology, clinical manifestations, and diagnosis of prosthetic valve endocarditis
- Adolf W Karchmer, MD
Adolf W Karchmer, MD
- Professor of Medicine
- Harvard Medical School
Prosthetic valve endocarditis (PVE) is a serious infection with potentially fatal consequences . (See "Complications and outcome of infective endocarditis", section on 'Outcome'.)
The pathogenesis, epidemiology, microbiology, pathology, clinical manifestations, and diagnosis of PVE will be reviewed here. The antimicrobial and possible surgical treatment and prevention of PVE are discussed separately. (See "Antimicrobial therapy of prosthetic valve endocarditis" and "Surgery for prosthetic valve endocarditis".)
Prosthetic valve endocarditis (PVE) can arise early or late after surgery. The timing of the infection reflects different pathogenic mechanisms that, in turn, influence the epidemiology, microbiology, pathology, and clinical manifestations of the infection.
Early infection — Microorganisms can reach the valve prosthesis by direct contamination intraoperatively or via hematogenous spread during the initial days and weeks after surgery. The organisms have direct access to the prosthesis-annulus interface and to perivalvular tissue along suture pathways because the valve sewing ring, cardiac annulus, and anchoring sutures are not endothelialized early after valve implantation. These structures are coated with host proteins, such as fibronectin and fibrinogen, to which some organisms can adhere and initiate infection.
Late infection — As the sewing ring, sutures, and adjacent tissues become endothelialized over the months following valve replacement, sites for adherence of microorganisms and access to host tissues adjacent to the prosthesis are altered. The pathogenesis of late PVE has been postulated to resemble native valve endocarditis (NVE). (See "Pathogenesis of vegetation formation in infective endocarditis".)
- Wang A, Athan E, Pappas PA, et al. Contemporary clinical profile and outcome of prosthetic valve endocarditis. JAMA 2007; 297:1354.
- Arvay A, Lengyel M. Incidence and risk factors of prosthetic valve endocarditis. Eur J Cardiothorac Surg 1988; 2:340.
- Calderwood SB, Swinski LA, Waternaux CM, et al. Risk factors for the development of prosthetic valve endocarditis. Circulation 1985; 72:31.
- Grover FL, Cohen DJ, Oprian C, et al. Determinants of the occurrence of and survival from prosthetic valve endocarditis. Experience of the Veterans Affairs Cooperative Study on Valvular Heart Disease. J Thorac Cardiovasc Surg 1994; 108:207.
- Brennan JM, Edwards FH, Zhao Y, et al. Long-term safety and effectiveness of mechanical versus biologic aortic valve prostheses in older patients: results from the Society of Thoracic Surgeons Adult Cardiac Surgery National Database. Circulation 2013; 127:1647.
- Rutledge R, Kim BJ, Applebaum RE. Actuarial analysis of the risk of prosthetic valve endocarditis in 1,598 patients with mechanical and bioprosthetic valves. Arch Surg 1985; 120:469.
- Ivert TS, Dismukes WE, Cobbs CG, et al. Prosthetic valve endocarditis. Circulation 1984; 69:223.
- Horstkotte D, Piper C, Niehues R, et al. Late prosthetic valve endocarditis. Eur Heart J 1995; 16 Suppl B:39.
- Agnihotri AK, McGiffin DC, Galbraith AJ, O'Brien MF. The prevalence of infective endocarditis after aortic valve replacement. J Thorac Cardiovasc Surg 1995; 110:1708.
- Hammermeister KE, Sethi GK, Henderson WG, et al. A comparison of outcomes in men 11 years after heart-valve replacement with a mechanical valve or bioprosthesis. Veterans Affairs Cooperative Study on Valvular Heart Disease. N Engl J Med 1993; 328:1289.
- Bloomfield P, Wheatley DJ, Prescott RJ, Miller HC. Twelve-year comparison of a Bjork-Shiley mechanical heart valve with porcine bioprostheses. N Engl J Med 1991; 324:573.
- Hammermeister K, Sethi GK, Henderson WG, et al. Outcomes 15 years after valve replacement with a mechanical versus a bioprosthetic valve: final report of the Veterans Affairs randomized trial. J Am Coll Cardiol 2000; 36:1152.
- Oxenham H, Bloomfield P, Wheatley DJ, et al. Twenty year comparison of a Bjork-Shiley mechanical heart valve with porcine bioprostheses. Heart 2003; 89:715.
- Stassano P, Di Tommaso L, Monaco M, et al. Aortic valve replacement: a prospective randomized evaluation of mechanical versus biological valves in patients ages 55 to 70 years. J Am Coll Cardiol 2009; 54:1862.
- Fang G, Keys TF, Gentry LO, et al. Prosthetic valve endocarditis resulting from nosocomial bacteremia. A prospective, multicenter study. Ann Intern Med 1993; 119:560.
- Nasser RM, Melgar GR, Longworth DL, Gordon SM. Incidence and risk of developing fungal prosthetic valve endocarditis after nosocomial candidemia. Am J Med 1997; 103:25.
- Chu VH, Miro JM, Hoen B, et al. Coagulase-negative staphylococcal prosthetic valve endocarditis--a contemporary update based on the International Collaboration on Endocarditis: prospective cohort study. Heart 2009; 95:570.
- Rivas P, Alonso J, Moya J, et al. The impact of hospital-acquired infections on the microbial etiology and prognosis of late-onset prosthetic valve endocarditis. Chest 2005; 128:764.
- Karchmer AW, Longworth DL. Infections of intracardiac devices. Infect Dis Clin North Am 2002; 16:477.
- Hill EE, Herregods MC, Vanderschueren S, et al. Management of prosthetic valve infective endocarditis. Am J Cardiol 2008; 101:1174.
- Lee JH, Burner KD, Fealey ME, et al. Prosthetic valve endocarditis: clinicopathological correlates in 122 surgical specimens from 116 patients (1985-2004). Cardiovasc Pathol 2011; 20:26.
- Karchmer AW, Archer GL, Dismukes WE. Staphylococcus epidermidis causing prosthetic valve endocarditis: microbiologic and clinical observations as guides to therapy. Ann Intern Med 1983; 98:447.
- Blumental S, Reynders M, Willems A, et al. Enteroviral infection of a cardiac prosthetic device. Clin Infect Dis 2011; 52:710.
- Richardson JV, Karp RB, Kirklin JW, Dismukes WE. Treatment of infective endocarditis: a 10-year comparative analysis. Circulation 1978; 58:589.
- Dismukes WE, Karchmer AW, Buckley MJ, et al. Prosthetic valve endocarditis. Analysis of 38 cases. Circulation 1973; 48:365.
- Ben Ismail M, Hannachi N, Abid F, et al. Prosthetic valve endocarditis. A survey. Br Heart J 1987; 58:72.
- Anderson DJ, Bulkley BH, Hutchins GM. A clinicopathologic study of prosthetic valve endocarditis in 22 patients: morphologic basis for diagnosis and therapy. Am Heart J 1977; 94:325.
- Rose AG. Prosthetic valve endocarditis. A clinicopathological study of 31 cases. S Afr Med J 1986; 69:441.
- Arnett EN, Roberts WC. Prosthetic valve endocarditis: clinicopathologic analysis of 22 necropsy patients with comparison observations in 74 necropsy patients with active infective endocarditis involving natural left-sided cardiac valves. Am J Cardiol 1976; 38:281.
- Karchmer AW. Infections of Prosthetic Heart Valves. In: Infections Associated with Indwelling Medical Devices, 3rd ed, Waldvogel FA, Bisno AL (Eds), American Society for Microbiology, Washington, DC 2000. p.145.
- Lytle BW, Priest BP, Taylor PC, et al. Surgical treatment of prosthetic valve endocarditis. J Thorac Cardiovasc Surg 1996; 111:198.
- Lepidi H, Casalta JP, Fournier PE, et al. Quantitative histological examination of bioprosthetic heart valves. Clin Infect Dis 2006; 42:590.
- Masur H, Johnson WD Jr. Prosthetic valve endocarditis. J Thorac Cardiovasc Surg 1980; 80:31.
- Tornos P, Sanz E, Permanyer-Miralda G, et al. Late prosthetic valve endocarditis. Immediate and long-term prognosis. Chest 1992; 101:37.
- Keyser DL, Biller J, Coffman TT, Adams HP Jr. Neurologic complications of late prosthetic valve endocarditis. Stroke 1990; 21:472.
- Karchmer AW, Dismukes WE, Buckley MJ, Austen WG. Late prosthetic valve endocarditis: clinical features influencing therapy. Am J Med 1978; 64:199.
- Calderwood SB, Swinski LA, Karchmer AW, et al. Prosthetic valve endocarditis. Analysis of factors affecting outcome of therapy. J Thorac Cardiovasc Surg 1986; 92:776.
- Lee A, Mirrett S, Reller LB, Weinstein MP. Detection of bloodstream infections in adults: how many blood cultures are needed? J Clin Microbiol 2007; 45:3546.
- Cockerill FR 3rd, Wilson JW, Vetter EA, et al. Optimal testing parameters for blood cultures. Clin Infect Dis 2004; 38:1724.
- Breen JD, Karchner AW. Usefulness of pulsed-field gel electrophoresis in confirming endocarditis due to Staphylococcus lugdunensis. Clin Infect Dis 1994; 19:985.
- Bayer AS, Bolger AF, Taubert KA, et al. Diagnosis and management of infective endocarditis and its complications. Circulation 1998; 98:2936.
- Bruun NE, Habib G, Thuny F, Sogaard P. Cardiac imaging in infectious endocarditis. Eur Heart J 2014; 35:624.
- Daniel WG, Mügge A, Grote J, et al. Comparison of transthoracic and transesophageal echocardiography for detection of abnormalities of prosthetic and bioprosthetic valves in the mitral and aortic positions. Am J Cardiol 1993; 71:210.
- Morguet AJ, Werner GS, Andreas S, Kreuzer H. Diagnostic value of transesophageal compared with transthoracic echocardiography in suspected prosthetic valve endocarditis. Herz 1995; 20:390.
- Khandheria BK. Transesophageal echocardiography in the evaluation of prosthetic valves. Am J Card Imaging 1995; 9:106.
- Stewart WJ, Shan K. The diagnosis of prosthetic valve endocarditis by echocardiography. Semin Thorac Cardiovasc Surg 1995; 7:7.
- Roe MT, Abramson MA, Li J, et al. Clinical information determines the impact of transesophageal echocardiography on the diagnosis of infective endocarditis by the duke criteria. Am Heart J 2000; 139:945.
- Cheitlin MD, Armstrong WF, Aurigemma GP, et al. ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to Update the 1997 Guidelines for the Clinical Application of Echocardiography). Circulation 2003; 108:1146.
- Daniel WG, Mügge A, Martin RP, et al. Improvement in the diagnosis of abscesses associated with endocarditis by transesophageal echocardiography. N Engl J Med 1991; 324:795.
- De Castro S, Cartoni D, d'Amati G, et al. Diagnostic accuracy of transthoracic and multiplane transesophageal echocardiography for valvular perforation in acute infective endocarditis: correlation with anatomic findings. Clin Infect Dis 2000; 30:825.
- Hill EE, Herijgers P, Claus P, et al. Abscess in infective endocarditis: the value of transesophageal echocardiography and outcome: a 5-year study. Am Heart J 2007; 154:923.
- Sochowski RA, Chan KL. Implication of negative results on a monoplane transesophageal echocardiographic study in patients with suspected infective endocarditis. J Am Coll Cardiol 1993; 21:216.
- Vieira ML, Grinberg M, Pomerantzeff PM, et al. Repeated echocardiographic examinations of patients with suspected infective endocarditis. Heart 2004; 90:1020.
- Feuchtner GM, Stolzmann P, Dichtl W, et al. Multislice computed tomography in infective endocarditis: comparison with transesophageal echocardiography and intraoperative findings. J Am Coll Cardiol 2009; 53:436.
- Gouriet F, Bayle S, Le Dolley Y, et al. Infectious endocarditis detected by PET/CT in a patient with a prosthetic knee infection: case report and review of the literature. Scand J Infect Dis 2013; 45:570.
- Saby L, Laas O, Habib G, et al. Positron emission tomography/computed tomography for diagnosis of prosthetic valve endocarditis: increased valvular 18F-fluorodeoxyglucose uptake as a novel major criterion. J Am Coll Cardiol 2013; 61:2374.
- Pizzi MN, Roque A, Fernández-Hidalgo N, et al. Improving the Diagnosis of Infective Endocarditis in Prosthetic Valves and Intracardiac Devices With 18F-Fluordeoxyglucose Positron Emission Tomography/Computed Tomography Angiography: Initial Results at an Infective Endocarditis Referral Center. Circulation 2015; 132:1113.
- Durack DT, Lukes AS, Bright DK. New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke Endocarditis Service. Am J Med 1994; 96:200.
- John MD, Hibberd PL, Karchmer AW, et al. Staphylococcus aureus prosthetic valve endocarditis: optimal management and risk factors for death. Clin Infect Dis 1998; 26:1302.
- Nettles RE, McCarty DE, Corey GR, et al. An evaluation of the Duke criteria in 25 pathologically confirmed cases of prosthetic valve endocarditis. Clin Infect Dis 1997; 25:1401.
- Early infection
- Late infection
- Healthcare-associated infection
- CLINICAL MANIFESTATIONS
- Signs and symptoms of invasive infection
- Blood cultures
- Approach to diagnosis
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS