title: Surgical treatment of prosthetic valve endocarditis in patients with double prostheses: is single-valve replacement safe?
abstract: OBJECTIVE
  Bias against operating on patients with prosthetic valve endocarditis (PVE) who have multiple prostheses may preclude the use of life-saving valve replacement. We investigated the accuracy of the preoperative diagnosis of PVE in patients with both mitral and aortic prosthesis and the safety of single-valve replacement when only one valve seemed infected.
  
  
  METHODS
  Patients with a diagnosis of active PVE who had mitral and aortic prosthesis in place were assessed. We looked at the methods for diagnosis, causative agents, indication for valve replacement, operative findings and outcome.
  
  
  RESULTS
  Twenty patients, who had both mitral and aortic prostheses and a diagnosis of PVE, were assessed. Streptococci and staphylococci caused 70% of cases. By means of echocardiography, the valves involved were: mitral (11 patients), aortic (six patients), and in three cases both prosthetic valves seemed infected. Surgery was undertaken in 17 patients (85%). The positive predictive value of transesophageal echocardiogram (TEE) for the preoperative diagnosis of the site of infection was 100%. In 13 patients, only the prosthetic valve that seemed infected was replaced. Four of these patients died within a week after the procedure. Nine patients survived the surgical procedure, completed a course of antimicrobial therapy and were followed up for 15.78 months (95% CI: 12.83-18.72). All were considered cured and relapses were not observed.
  
  
  CONCLUSIONS
  TEE allowed a diagnosis of site involvement that did correlate with the anatomic diagnosis obtained during the operation. This fact contributed to the management of patients and was of great help in guiding the surgical intervention. Echo-oriented single-valve replacement may be a safe strategy for patients with PVE and double prostheses.
authors.affiliation: Division of Infectious Diseases, Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Madrid, Spain. mlfernandez@fjd.es
authors.forename: Manuel L Fernández
authors.initials: ML
authors.lastname: Guerrero
authors.forename: Julio
authors.initials: J
authors.lastname: Alonso
authors.forename: Manuel
authors.initials: M
authors.lastname: Rey
authors.forename: Jorge
authors.initials: J
authors.lastname: Martinell
authors.forename: Miguel
authors.initials: M
authors.lastname: Górgolas
authors.forename: Victor
authors.initials: V
authors.lastname: Artiz
authors.forename: Julian
authors.initials: J
authors.lastname: Fraile
mesh_terms: D000368:Aged; D001021:Aortic Valve / Q000000981:diagnostic imaging / Q000382:microbiology / Q000601:surgery*; D017548:Echocardiography, Transesophageal; D004697:Endocarditis, Bacterial / Q000000981:diagnostic imaging / Q000382:microbiology / Q000601:surgery*; D005260:Female; D006350:Heart Valve Prosthesis / Q000009:adverse effects*; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000379:methods*; D006801:Humans; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000000981:diagnostic imaging / Q000382:microbiology / Q000601:surgery*; D016459:Prosthesis-Related Infections / Q000000981:diagnostic imaging / Q000382:microbiology / Q000601:surgery*; D012189:Retrospective Studies; D016896:Treatment Outcome