Surgical management of late prosthetic valve endocarditis

Among 32 patients with late prosthetic valve endocarditis selected from two cooperative retrospective studies, ten had valve replacement: six men and four women, mean age being 48 years, ranging from 23 to 65 years old. An emergency reoperation was undertaken for refractory heart failure in seven out of ten cases, with an average delay of 6.6 days after the beginning of antibiotic therapy. In the other three cases, the operation was carried out at the end of 40 days of antibiotic therapy, once for recurrent endocarditis and twice for severe aortic insufficiency. The most common causative micro organism was the staphylococcus (7 out of 10 cases). The infected prosthetic valves were, in 8 out of the 10 cases, in the aortic position. The outcome was poor as the mortality rate was 60% (6 out of the 7 patients operated on in an emergency). Death was attributed to heart failure with conduction disturbances and severe aortic regurgitation (2 cases), cerebral emboli (2 cases), septicopyemia (2 cases). Four patients of the ten, after a mean follow up of 10 months, are cured without prosthetic valve dysfunction. The extreme gravity of prognosis seems related to the microorganism (staphylococcus), to the delay between the beginning of antibiotic therapy and the onset of the fever, and finally to the extension of destructive lesions under the prosthetic valve implantation base; the reimplantation of the prosthesis on frail and abscessed tissue implies a substantial risk of disinsertion. The indications for systematic early reoperation in cases of severe acute heart failure are discussed.