title: Fungal prosthetic valve endocarditis in 16 patients. An 11-year experience in a tertiary care hospital.
abstract: Fungal prosthetic valve endocarditis (PVE) is an infrequent but serious complication of valve replacement surgery. To examine its long-term outcome, we retrospectively studied 16 patients with 19 episodes of definite fungal PVE. The mean age was 51 years (range, 27-71 yr). Onset of fungal PVE ranged from 8 days to 3.4 years after valve replacement. Candida albicans was the most common (56%) pathogen isolated. A portal of entry was identified in only 25% of the patients; the presence of intravascular catheters (50%) and prior bacterial endocarditis (38%) were leading predisposing factors. Fever (83%) was the most consistent clinical finding. Potentially serious embolic events, particularly strokes (32%), were common at presentation. Transesophageal echocardiography (sensitivity = 100%) was more useful than transthoracic echocardiography (sensitivity = 60%) in detecting lesions due to fungal PVE. Combined valve replacement surgery and amphotericin B (mean total dose of 1.8 g) in 15 patients resulted in an 87% in-hospital survival and 67% overall survival with a mean follow-up of 4.5 years (range, 5 mo to 16 yr). Two patients had 3 late relapses of fungal PVE up to 9 years after the preceding episode. Each relapse was treated with repeat valve replacement and amphotericin B; in addition, oral azole was utilized for chronic suppression, although the efficacy of this strategy remains unproven. Because of the possibility of relapse, long-term follow-up is essential even after surgical and prolonged antifungal therapy.
authors.affiliation: Department of Medicine, Cleveland Clinic Foundation, OH 44195, USA.
authors.forename: G R
authors.initials: GR
authors.lastname: Melgar
authors.forename: R M
authors.initials: RM
authors.lastname: Nasser
authors.forename: S M
authors.initials: SM
authors.lastname: Gordon
authors.forename: B W
authors.initials: BW
authors.lastname: Lytle
authors.forename: T F
authors.initials: TF
authors.lastname: Keys
authors.forename: D L
authors.initials: DL
authors.lastname: Longworth
mesh_terms: D000328:Adult; D000368:Aged; D004696:Endocarditis / Q000175:diagnosis / Q000209:etiology / Q000628:therapy; D005260:Female; D006350:Heart Valve Prosthesis / Q000009:adverse effects*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009181:Mycoses / Q000175:diagnosis / Q000628:therapy; D011379:Prognosis; D016459:Prosthesis-Related Infections / Q000175:diagnosis / Q000628:therapy; D012189:Retrospective Studies; D012307:Risk Factors