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Ann Thorac Surg 2000;69:1388-1392
© 2000 The Society of Thoracic Surgeons
a Departments of Department of Infectious Diseases, Cleveland Clinic Foundation, Cleveland, Ohio, USA
b Department of Infection Control, Cleveland Clinic Foundation, Cleveland, Ohio, USA
c Department of Cardiothoracic Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
Address reprint requests to Dr Gordon, Department of Infectious Diseases, The Cleveland Clinic, 9500 Euclid Ave, Mailstop S32, Cleveland, OH 44195-5066
e-mail: gordons{at}cesmtp.ccf.org
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Abstract |
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 Top Abstract IntroductionMaterial and methodsResultsCommentReferences |
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Methods. Cases were defined by the Duke criteria and identified through prospective surveillance.
Results. Seventy-seven cases of EO-PVE were identified (1 per 100 procedures), and during the study period the incidence of EO-PVE decreased from 1.5% (1992 to 1994) to 0.7% (1995 to 1997) (p < 0.01). The incidence of EO-PVE for rings (0.2%; 4 of 1,992) was significantly lower than for mechanical (1.6%; 28 of 1,731) and bioprosthetic valves (1.1%; 41 of 3,320) (p < 0.001). The incidence of EO-PVE was also significantly lower for mitral valve versus aortic valve surgeries (0.6% versus 1.4%, p < 0.001). The most common pathogens causing EO-PVE were coagulase-negative staphylococci (52%), fungi (13%), Staphylococcus aureus (10%), and enterococci (8%). Patients undergoing combined surgical and medical treatment of EO-PVE had a significantly higher 30-day, 2-year, and 3-year survival than medically treated patients, although patients judged to be too ill to survive surgery accounted for two-thirds of the patients treated medically.
Conclusions. There is a 1% incidence rate of EO-PVE among patients undergoing valve operations at our institution, usually caused by coagulase-negative staphylococci, and combined surgical and medical treatment is associated with improved survival compared with medical treatment alone.
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Introduction |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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Material and methods |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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Case definition of early onset prosthetic valve endocarditis
A case-patient was defined as any patient undergoing a heart valve replacement or repair at CCF who developed prosthetic valve endocarditis within 12 months of valve replacement operation. We defined endocarditis according to the Duke criteria [6]. We also assessed case-patients according to the criteria of von Reyn and colleagues [7] for the diagnosis of definitive endocarditis.
Case ascertainment
Case-patients were identified through a prospective surveillance system for prosthetic valve endocarditis maintained by the department of infection control since 1992. Case-patients were cross referenced with the Cardiac Valve Information Registry at CCF, a computerized database that contains information on all open heart procedures performed since 1970.
Data were abstracted from the medical records of case-patients including the type of prosthetic valve infected (ring, bioprosthetic, or mechanical), the date the prosthesis was inserted, the date of onset of EO-PVE, the pathogen, the clinical decision for surgical versus medical treatment only, and operative reports. Pathology and postmortem reports as well as autopsy reports were obtained for verification of explanted valve histopathologic findings. Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) results were obtained from reports in patients’ medical records.
One investigator (S.M.G.) made follow-up telephone calls in May 1999 to interview all available patients. Inquiries were made to patients or their surrogates about state of health, recurrence of illness, fever, and complications relating to treatment of prosthetic valve endocarditis. Other sources of follow-up information included referring physicians and results of routine longitudinal follow-up performed by the departments of cardiothoracic surgery and infectious diseases.
Outcome measurements
The primary end points for the study were survival at 30 days and 1, 2, and 3 years after combined surgical-medical treatment versus medical treatment alone of EO-PVE. Incidence rates were calculated for type of prosthetic valve (bioprosthetic versus mechanical versus ring) and valve location (aortic, mitral, or both), as well as surgeon-specific rates of EO-PVE.
Statistical analysis
Data were analyzed using version 6.02 EPIINFO [8]; 
2 or Fisher’s two-tailed exact tests were used to assess the significance of association when appropriate. Potential risk factors were analyzed by univariate analysis to identify differences between the two groups (surgical versus medical) of patients with EO-PVE.
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Results |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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A total of 15 attending cardiothoracic surgeons performed valve operations during the study period (eight surgeons performed more than 200 valve procedures). There were no statistically significant differences between surgeon-specific rates of EO-PVE (range, 0 to 2 cases per 100 procedures).
Patient characteristics
The mean age of the 77 patients with EO-PVE was 64.6 years (range, 17 to 87 years); 73% were men and 25% were diabetic. Twenty-two percent had a prior valve operation before the index valve replacement, and 13% (10 patients) had infective endocarditis as the reason for their index valve replacement or repair. The median interval between valve operation and the onset of signs and symptoms of EO-PVE was 120 days (range, 1 to 361 days).
Diagnostic criteria for prosthetic valve endocarditis
All 77 patients met Duke criteria for diagnosis of definitive infective endocarditis [6] and 78% (60 patients) met the criteria of von Reyn and associates [7] for definitive endocarditis. Seventy-nine percent (63 patients) had a positive echocardiogram for endocarditis (vegetation or abscess), 53% (41 patients) had pathologic evidence of endocarditis at operation or postmortem examination, and 46% (34 patients) had a positive culture of the explanted prosthetic valve.
Among the 43 patients who had both a TEE and a TTE performed at the time of diagnosis of EO-PVE, both the TEE and TTE were positive in 39% (17 patients); only the TEE was positive in 46% (20 patients); only the TTE was positive in 2% (1 patient); and both TEE and TTE were negative in 12% (5 patients).
The sensitivity of TTE and TEE in the diagnosis of the 60 cases of EO-PVE meeting the criteria of von Reyn and colleagues [7] was 46% (17 of 37 patients) and 90% (45 of 50 patients), respectively.
Pathogens causing early onset prosthetic valve endocarditis
The most common pathogens were coagulase-negative staphylococci (52%), fungi (13%), Staphylococcus aureus (10%), and enterococci (8%). Other pathogens included viridans streptococci (5%), Enterobacter aerogenes (2.5%), Pseudomonas aeruginosa (1.3%), Serratia marcescens (1.3%), Corynebacterium jeikeium (1.3%), and culture-negative cases that were proven histopathologically (2.5%). The 10 fungal cases included Candida albicans (8 cases), Candida parapsilosis, and Acromonium species (1 case each). Sixty-nine patients (90%) had documented bacteremia or fungemia at the time of diagnosis of EO-PVE, and 50% of the eight S. aureus isolates were resistant to methicillin.
Treatment and outcome of early onset prosthetic valve endocarditis
Fifty-four patients (70%) underwent valve replacement operation during antimicrobial therapy for treatment of EO-PVE. The median time to operation from onset of EO-PVE was 30 days (range, 2 to 130 days).
Twenty-three patients (30%) were treated for EO-PVE with antimicrobial therapy alone. Among patients treated medically, 14 patients (61%) were judged not to be surgical candidates or too ill to undergo an open heart operation. Eight of these patients (57%) died within 3 weeks of diagnosis, and 3 patients (21%) were alive 1 year after diagnosis of EO-PVE. Two of 23 patients (10%) treated medically refused surgical treatment, and the remaining 7 patients had no cardiac complications (heart failure, heart block, paravalvular abscess, or valve dehiscence) requiring surgical intervention at the time of diagnosis of EO-PVE. The pathogens causing prosthetic valve endocarditis among these 7 patients included coagulase-negative staphylococci (2), viridans streptococci (2), Candida (2), and Enterococcus (1). At 1 year after diagnosis of EO-PVE, 3 patients (43%) were alive, 3 patients had died, and 1 patient was lost to follow-up.
A total of 73% (32 patients) of the 54 survivors were successfully contacted by telephone in May 1999. The median interval from onset of EO-PVE to follow-up for these patients was 1,681 days (range, 328 to 2,559 days). The 12 patients who could not be reached by telephone included 3 patients who were treated medically and 9 patients treated surgically. The median interval from onset of EO-PVE to follow-up for patients lost to follow-up was 902 days (range, 44 to 1,721 days). The reasons for no telephone follow-up included patients residing overseas (3 patients), no phone number listed (8 patients), and no answer after repeated attempts (1 patient).
Patients undergoing valve replacement operations for treatment of EO-PVE had a significantly higher survival compared with medically treated patients at 30 days (92% [50 of 54] versus 65% [15 of 23], p = 0.004; risk ratio = 0.21; 95% confidence interval, 0.07 to 0.64); a higher 1-year survival (74% [39 of 53] versus 40% [8 of 20]; p = 0.02; risk ratio = 0.44; 95% confidence interval, 0.25 to 0.78); a higher 2-year survival (65% [32 of 49] versus 37% [7 of 19]; p = 0.04; risk ratio = 0.53; 95% confidence interval, 0.32 to 0.88); and a higher 3-year survival (61% [28 of 46] versus 33% [6 of 18]; p = 0.06; risk ratio = 0.57; 95% confidence interval, 0.36 to 0.92; Table 1).
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One of the 4 patients who was treated medically had a relapse of enterococcal prosthetic valve endocarditis and died within 1 year. A postmortem examination documented a septic coronary embolism. Two of 8 patients with medically treated EO-PVE who survived more than 1 year after diagnosis subsequently required reoperations for valvular incompetence with evidence of healed prosthetic valve endocarditis found at the time of operation in both cases.
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Comment |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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One strength of our study is the relatively large numbers of valvular procedures performed by surgeons in a single medical center during a short enough time to avoid confounding effects of changes in technique, management, and diagnosis of prosthetic valve endocarditis. Our incidence of EO-PVE fell within the range of previous reports [1–4], and 83% (77 of 93) of all identified cases of prosthetic valve endocarditis in our cohort of patients during the study period were EO-PVE. Notably, the incidence rate of EO-PVE fell significantly during the 6-year period. The reason for the decline in rate could not be attributed to changes in surgical staff, antibiotic prophylaxis, or a change in surveillance. We believe it reflects increasing surgical experience and expertise in a high-volume cardiovascular surgery center. In part, the decline in EO-PVE may be attributed to an increasing trend for mitral valve repairs versus replacements (repairs accounted for almost 75% of mitral valve procedures in 1997 versus 63% in 1992) and a decrease in the use of mechanical prostheses and an increased use of homografts and bioprostheses for aortic valve procedures (18% mechanical prostheses in 1997 versus 40% in 1992).
By the Centers for Disease Control and Prevention definitions, an infection involving an implanted prosthetic device within the first 12 months of an operative procedure is considered to be a nosocomial infection and more likely to be acquired at the time of operation [9]. The microorganisms responsible for EO-PVE in our study were similar to other reported series, with coagulase-negative staphylococci accounting for more than 50% of cases [10]. It is notable that fungi were our second most prevalent pathogen associated with EO-PVE, accounting for 13% of our cases. Although fungal endocarditis secondary to extrinsic valve contamination is rare, a recent report identified a case of C albicans EO-PVE associated with a contaminated aortic valve homograft [11]. Four of our cases of EO-PVE (three C albicans and one Acromonium species) occurred after implantation of aortic homografts (two with conduits) with a mean onset of 4.5 weeks of implantation (range, 1 to 32 weeks).
Surgical treatment of prosthetic valve endocarditis in our institution has evolved in the direction of increasingly radical debridement of infected tissue and reconstruction with biological materials. We have previously published our experience of 146 patients operated on for prosthetic valve endocarditis (including 46 patients with EO-PVE) between 1975 and 1992 [12]. The 5-year survival was 71%, with subsequent reoperations performed for 15% of in-hospital survivors.
In the current study, surgical treatment of EO-PVE was associated with improved short-term and long-term survival when compared with treatment with antibiotics alone (61% versus 32% at 3 years). However, it must be emphasized that patients judged to be too ill to survive operation accounted for almost two thirds of the patients treated medically, of whom 57% died within 30 days of onset of EO-PVE. The definition of poor surgical candidate remains an elusive one but is the major factor in determining who does not receive surgical treatment of EO-PVE in our institution. Because our study was observational and not designed to compare surgical versus medical treatment, caution is needed in interpreting treatment results. Other important limitations to our findings include (1) the possibility of misclassification of some medically treated patients who may not have had EO-PVE (no definitive histopathology); (2) incomplete follow-up on 14% of the study cohort with EO-PVE and possible incomplete case finding; (3) the small number of cases; and (4) CCF being a referral center may affect the interhospital comparison of our rates of prosthetic valve endocarditis. Nonetheless, we believe that all patients with EO-PVE and cardiac complications (heart failure, heart block, paravalvular abscess, or valve dehiscence) require consideration of early surgical intervention, followed by prolonged antimicrobial therapy.
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