Midterm Evaluation of Biological Prosthetic Valves in the Pulmonary Position of Grown-Up Patients

Mestres C, Bautista-Hernandez V. Prosthetic pulmonary valve and conduit endocarditis in congenital heart disease

Background

Pulmonary valve replacement is one of the most common procedures in patients with congenital heart disease. Little is known about prosthetic valve endocarditis in this population.

Objectives

To review management and outcomes of pediatric and adult patients with a prosthetic pulmonary valve or right ventricle-to-pulmonary artery conduit infective endocarditis.

Methods and results

A multiinstitutional cohort of 10 patients is reported. Median age at endocarditis was 24 years (range 8–41 years). The most common causative organisms were Staphylococcus ( n = 4) and Streptococcus species ( n = 2). In addition to medical treatment, 5 patients required surgery. Majors complications such as renal damage, life-threatening hemoptysis, and septic shock were observed. No patient died in hospital or during follow-up.

Conclusions

Pulmonary prosthetic valve endocarditis is a rare condition associated with significant morbidity and a high risk of requiring operative intervention. Larger studies are required to optimize the management.

A Systematic Review of Infective Endocarditis in Patients With Bovine Jugular Vein Valves Compared With Other Valve Types

OBJECTIVES

The aim of this study was to systematically evaluate the incidence of infective endocarditis (IE) in right ventricle-to-pulmonary artery conduits and valves, comparing bovine jugular vein (BJV) valves with all others.

BACKGROUND

Recent evidence suggests that the incidence of IE is higher in patients with congenital heart disease who have undergone implantation of BJV valves in the pulmonary position compared with other valves.

METHODS

Systematic searches of published research were conducted using electronic databases (MEDLINE, Embase, and CINAHL) and citations cross-referenced current to April 2016. Included studies met the following criteria: patients had undergone right ventricle-to-pulmonary artery conduit or percutaneous pulmonary valve implantation, and investigators reported on the type of conduit or valve implanted, method of intervention (surgery or catheter based), IE incidence, and follow-up time.

RESULTS

Fifty studies (Levels of Evidence: 2 to 4) were identified involving 7,063 patients. The median cumulative incidence of IE was higher for BJV compared with other valves (5.4% vs. 1.2%; p < 0.0001) during a median follow-up period of 24.0 and 35.5 months, respectively (p = 0.03). For patients with BJV valves, the incidence of IE was not different between surgical and catheter-based valve implantation (p = 0.83).

CONCLUSIONS

There was a higher incidence of endocarditis with BJV valves than other types of right ventricle-to-pulmonary artery conduits. There was no difference in the incidence of endocarditis between catheter-based bovine valves and surgically implanted bovine valves, suggesting that the substrate for future infection is related to the tissue rather than the method of implantation.

Late postoperative prosthetic pulmonary valve endocarditis in a 13-year-old girl with repaired tetralogy of fallot

Prosthetic pulmonary valve endocarditis has infrequently been described outside large cohort reviews, which have typically focused on infections of the left-sided heart valves. Hence, the pathogenesis, clinical presentation, and management principles of prosthetic pulmonary valve endocarditis have not been well differentiated from those of infected aortic and mitral valves. More patients with repaired tetralogy of Fallot are reaching adulthood and will need pulmonary valve implantation. Consequently, a focus on this infrequent but serious cardiac infection is needed, to learn what characteristics might distinguish it from infections of left-sided heart valves. We report the case of a 13-year-old girl with repaired tetralogy of Fallot who presented with fever and nonspecific symptoms. The patient initially failed to meet the Duke criteria for endocarditis but was then found to have endocarditis of her prosthetic pulmonary valve. We explanted the valve and replaced it with a pulmonary homograft, after which the patient had no infectious sequelae. In addition to presenting the patient's case, we review the literature on surgically inserted prosthetic pulmonary valves and discuss the primary management concerns when those valves become infected with endocarditis.