[HSF] re:bioprosthetic valve endocarditis

Tea Acuff tacuff at swbell.net
Sat Jan 12 13:20:48 EST 2008 

Positive blood cultures or sepsis and prosthetic heart valve does not equal infected prothesis.

tea


----- Original Message ----
From: Zhandong Zhou <zzhoumd at pol.net>
To: OpenHeart-L at lists.hsforum.com
Sent: Saturday, January 12, 2008 10:55:04 AM
Subject: Re: [HSF] re:bioprosthetic valve endocarditis

Bob, that sounds reasonable. It is understandable that pending emboli is the main concern. For patients come with emboli, should we operate them right away without any treatment? My approach is dependent on the TEE. If the patient has large vegetation or looks like loose vegetation, then surgery should be offered.

In the case we discussed, no vegetation was seen on the echo, so the chance of pending embolization is small, so medical treatment is reasonable. If he has large vegetation with good chance of embolization, then surgery should be offered sooner. Even in our practice, we still see patients with missed diagnosis like the one died recently. However, I do have successful story as well. Recently I had a young female patient with IV drug use developed staphy infection of the mitral valve and embolized brain at presentation. The embolic area then become hemorragic next day. She was treated with antibiotics and had craniotomy. She was remarkable improved with antibiotics and I was able to repair the valve 6 weeks later. During surgery, her valve was completely healed with just scar tissue  and ruptured cords in P1 area. Her mother works in my hospital and they are so happy that I did not have to put a prosthetic valve in a her. (only 23 year old)

Hope that will help.

Z  Zhou



----- Original Message ----- 
From: <rwmfglycar at aol.com>
To: <OpenHeart-L at lists.hsforum.com>
Sent: Saturday, January 12, 2008 10:30 AM
Subject: Re: [HSF] re:bioprosthetic valve endocarditis


> Let me try to clarify. A patient is sent to the surgeons with?endocarditis (note I said of any valve) but the truly emergent ones were usually neglected native valves. The valve is flail (aortic or mitral). The patient is in pulmonary oedema., and often?has a low cardiac output. It is rare to be able to get a patient like this to a really stable state. Multiple cultures are taken and antibiotics are started sometimes with knowledge of bacterial species and sensitivity and sometimes not. Sometimes surgery is needed immediately (particularly with aortic valve rupture with cardiogenic shock). We took most of our patients who presented like this? to surgery by 48 hours. These are the patients whose valve cultures are generally negative after only 48 hours of treatment. (Obviously a 1cm and larger?vegetation is likely to grow something from its center). 
> These patients were the product of a disadvantaged poor population. They were very unlikely to be seen in private. 
> Mechanical or bioprosthetic valve endocarditis were less likely to present with acute cardiac failure and more easy to get to a stable cardiac state. However because of our experience with the acute cases we always advised going to surgery before any arbitrary completion of an antibiotic course. The ones I really hated waiting on were the ones who had already had an embolus. I had a couple of sad cases who threw another devastating embolus while waiting for a stubborn internist /cardiologist to complete his utterly unproven policy of giving a "complete" course of antibiotics. I realise there are still dinosaurs out there who think in terms of "positive blood culture = 6 wks antibiotics". There are also surgeons who are afraid of operating on endocarditis and use the arbitrary requirement of 6 wkd antibiotic Rx as a form of triage.
> But surely there is another way. If surgery is indicated and the blood is sterile do it now,
> Bob
> ?
> I hope this makes my meaning clear.
> Bob
> 
> 
> -----Original Message-----
> From: Zhandong Zhou <zzhoumd at pol.net>
> To: OpenHeart-L at lists.hsforum.com












> Sent: Sat, 12 Jan 2008 9:45 am
> Subject: Re: [HSF] re:bioprosthetic valve endocarditis
> 
> 
> 
> did I missed something, you operate on anybody walk into the hospital with 
> prosthetic valve endocarditis without any treatment first? 
> 
> I do not believe this is the standard of care or it is changed now? There are 
> people need emergent surgery, but there are people do not need a surgery. 
> 
> I think the patient population you are seeing does not represent the general 
> population.
> 
> Z Zhou
> 
> ----- Original Message ----- 
> From: <rwmfglycar at aol.com>
> To: <OpenHeart-L at lists.hsforum.com>
> Sent: Saturday, January 12, 2008 8:35 AM
> Subject: Re: [HSF] re:bioprosthetic valve endocarditis
> 
> 
>> In the Bronx we were often forced to operate emrgently for endocarditis of any 
> type. With acute heart failure there is no time to wait for completion of 
> an?antibiotic course. We found that we very rarely got a positive culture from 
> the valve in a patient with a sensitive organism after 48 hours of antibiotics. 
>>>From this experience we developed a policy of never waiting?if there was a a 
> cardiac indication for urgent surgery. If the patient had an organism that was 
> resistant to available antibiotic treatment that was , itself, an indication for 
> urgent surgery. Our reinfection rate was close to nonexistent and the risk of 
> surgery definitely lower than it was when we tried?in the early days?to wait as 
> long as possible for a textbook course of antibiotics to be completed.
>> Bob
>> 
>> 
>> -----Original Message-----
>> From: zzhoumd at pol.net
>> To: OpenHeart-L at lists.hsforum.com
>> Sent: Sat, 12 Jan 2008 9:47 pm
>> Subject: Re: [HSF] re:bioprosthetic valve endocarditis
>> 
>> 
>> 
>> 
>> Ani, the main reason to avoid surgery in acute phase is high risk and 
>> re-infection rate. As to the case I presented earlier, my patient had fever 
> and 
>> chills for 10 days before he had echocardiogram and the bacteria was 
>> Enterococcus which is very difficult to treat. Also, he has a mechanic valve 
>> which usually casue infection in the annulus. This patient has a 
> bioprosthesis, 
>> so the infection is more likely on the valve, not annulus. The bacteria is 
> Strep 
>> so the treatment is more likely to be successful. If you operate on elective 
>> bases, surgery is much easier. However, if no improvement in 2-3 days with 
>> antibiotics, surgery should be offered.
>> 
>> Prosthetic valve endocarditis itself is relative indication depends on the 
> type 
>> of bacteria, not absolute indication.
>> 
>> I hope you will agree.
>> 
>> Z Zhou
>> 
>> Sent via BlackBerry by AT&T
>> 
>> -----Original Message-----
>> From: Ani Anyanwu <anianyanwu at hotmail.com>
>> 
>> Date: Fri, 11 Jan 2008 15:14:43 
>> To:<openheart-l at lists.hsforum.com>
>> Subject: RE: [HSF] re:bioprosthetic valve endocarditis
>> 
>> 
>> If he meets criteria for endocarditis it then begs the question what exactly 
> are 
>> we observing for? We do far more operations for less certain benefit (such as 
>> CABG) where we treat many to prevent one death. In this case the numbers 
> needed 
>> to treat are small as few patients as you say would survive this without 
>> surgery.
>> 
>> Are we observing to wait for the patient to develop an abscess or another 
>> embolization? This patient is young and by definition will need another 
>> operation - why not do it now the surgical risk may be lower than when the 
> whole 
>> root is a big abscess and we face what Dr Zhou faced recently?
>> 
>> We had a young 34 yr old woman, although with native valve endocarditis,  who 
>> also had peripheral emboli and was also being observed closely on antibiotics 
>> (we recommended surgery but cardiology and ID thought valve can be sterilized) 
> 
>> she went to california for christmas 2006 and then developed another 
> indication 
>> requiring emergency surgery which was further embolization - to her retinal 
>> artery. She remains blind in one eye till this day.
>> 
>> I think observation is acceptable strategy in elderly patients with prosthetic 
> 
>> valve endocarditis as such patients still may out live the valve (because of 
>> surgical mortality mainly) but in a young patient I struggle to find a 
>> justification for non-surgical management of prosthetic valve endocarditis.
>> 
>> Ani
>> 
>> 
>> 
>>> To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] re:bioprosthetic valve 
>> endocarditis> Date: Fri, 11 Jan 2008 02:16:34 -0500> From: rwmfglycar at aol.com> 
> 
>> CC: > > Ani, this one was clearly endocarditis. There were?emboli which 
>> remarkably resolved quickly with antibiotics. The inference is that > these 
> were 
>> very fresh platelet ,fibrin and bacterial?aggregations, which the patient 
> lysed 
>> rapidly. I would have operated on this patient but now that we have reached a 
>> different stage, it looks as though the antibiotics may sterilise this valve. 
>> With a bioprosthesis the infection can be confined to the leaflets. Note that 
>> short of a tear we don't actually know how much damage the infection has 
>> caused.?> If the decision is made to treat conservatively "success" is 
> possible. 
>> But the obligation for very close followup for at least 6 months is extreme. 
> At 
>> the slightest hint of a return of signs or symptoms the patient should go to 
>> surgery. This opinion?is based on bad experiences when internists or 
>> cardiologists, even Infectious Disease specialists have elected to have 
> another 
>> go at at sterilising?a valve previously diagnosed as infected.> Bob> > 
>> -----Original Message-----> From: Ani Anyanwu <anianyanwu at hotmail.com>> To: 
>> openheart-l at lists.hsforum.com> Sent: Thu, 10 Jan 2008 8:20 am> Subject: RE: 
>> [HSF] re:bioprosthetic valve endocarditis> > > > I might have missed part of 
> the 
>> clinical course but my impression thus far is > that we do not know this 
> patient 
>> has endocarditis and all we have is positive > blood cultures so far? Although 
> 
>> you might be able to push a diagnosis based on > positive culture plus 3 minor 
> 
>> (duke) criteria in this setting without echo > evidence I doubt we can 
>> clinically rule in endocarditis.> > But assuming it is endocarditis, Hal And 
> Dr 
>> Zhou, in such a young patient would > you really agree with observation as a 
>> course of action for prosthethic valve > endocarditis in a patient who is a 
>> surgical candidate?> > Ani> > > > > From: Hgrmd at aol.com> Date: Thu, 10 Jan 
> 2008 
>> 07:24:46 -0500> Subject: Re: [HSF] > re:bioprosthetic valve endocarditis> To: 
>> OpenHeart-L at lists.hsforum.com> CC: > > > Prasanna and Carmi,> If the patient's 
> 
>> symptoms have devervesced on antibiotics, > then > observation is in order. 
>> Unless there is persistent fever/bacteremia, > leukocytosis, > vegetations, or 
> 
>> paravalvular leak, there is no indication for > surgery. I've > seen 
> occasional 
>> sterilization of infected prostheses.> > Hal> > > > > **************Start the 
>> year off right. Easy ways to stay in shape. > > http://body.aol.com/fitness/winter-exercise?NCID=aolcmp00300000002489> 
> 
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