The impact of transesophageal echocardiography on the management of prosthetic valve endocarditis: experience of 31 cases and review of the literature.

BACKGROUND AND AIMS OF THE STUDY

Although prosthetic valve endocarditis (PVE) still has a poor prognosis, early diagnosis may improve clinical outcome. This study was designed to assess the diagnostic ability of transesophageal echocardiography (TEE) in PVE and compare clinical outcome in patients treated before and after the onset of complications.

METHODS

Thirty one patients, each with PVE determined by morphologic or clinical Duke criteria, were studied. Patients were divided into two groups: group I (17 patients) presented with clinical complications of PVE; group II (14 patients) had no such clinical complications. There was no difference between groups in the type of prosthesis, location of PVE, type of PVE (early or late), or bacteriological findings. All patients underwent transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE); the latter was performed by a multiplane technique in 20 of the 31 cases.

RESULTS

TTE detected vegetations in two cases and abscesses in four, while TEE showed vegetation in 21 and abscess in 14. Prosthetic valve obstruction was found in five cases by both techniques, while paravalvular leak was detected in 12 cases by TEE and in nine by TTE. Left atrial vegetation was detected by TEE in two cases. Ten patients were treated medically, six of whom died (all five who were in group I; one of five in group II). In total, 21 patients were operated on, all in the active phase. The operative mortality was 38% (seven of 12 in group I (58%); one of nine in group II (11%)).

CONCLUSIONS

These studies showed that: (i) TEE provides the clinical criteria of PVE in 50% of the cases; (ii) TEE facilitates the treatment of PVE before the development of complications such as congestive heart failure and embolism; (iii) mortality is significantly lower in patients treated either surgically or medically before these complications develop; and (iv) surgery should not be delayed until congestive heart failure develops.