Echocardiography. 2019;36:815–816. wileyonlinelibrary.com/journal/echo © 2019 Wiley Periodicals, Inc.
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815 DOI: 10.1111/echo.14287L E T T E R T O T H E E D I T O R / R E P LY
Fundamental role of echocardiographic evaluation in the
diagnosis of prosthetic valve endocarditis
To the Editor,
We have recently read with great interest the article by Carneiro et al entitled “Fungal prosthetic aortic valve endocarditis and end-arteritis: An unusual cause of aortic root vegetations”.1 The authors reported a case of fungal aortic prosthetic valve endocarditis (PVE), which was successfully treated with antibiotic therapy plus surgical intervention. We congratulate the authors for achieving a successful outcome in such a high- risk patient. On the other hand, we believe that there are some major drawbacks that need to be addressed.
Prosthetic valve endocarditis caused by Candida spp. is a rare but potentially lethal disease. In the most recent study, inhospital mor-tality and overall mormor-tality rates have been reported to increase up to 30% and 56%, respectively.2 Regarding the recommendations of American College of Cardiology (ACC)/American Heart Association (AHA) and European Society of Cardiology (ESC)/European Association for Cardiothoracic Surgery (EACTS) guidelines for the management of infective endocarditis, fungal PVE and as its compli-cations including aortic abscess and destructive penetrating lesions (aneurysm) should be treated (Class 1- B) by antifungals combined with early surgery.3,4
The most important drawback in this case report was that, de-spite a 3/4 diastolic murmur was detected during physical exam-ination during the first admission of the patient to the emergency service after aortic valve replacement, he was not evaluated with bedside transthoracic echocardiography (TTE) or transesophageal echocardiography (TEE). If this had been done, the diagnosis of the fungal PVE could be detected earlier.
Two days later, the patient was re- admitted to the emergency room with acute leg ischemia and subacute thrombosis in the right common femoral artery was treated successfully with surgical em-bolectomy. Before this interventional treatment, it is uncertain in the case report whether the patient had been evaluated for pos-sible causes of cardioembolism (such as vegetation or prosthetic valve thrombosis) or not? The major cardiovascular guidelines re-garding infective endocarditis recommend that if the clinical sus-picion of PVE or its complications is high (such as prosthetic valve regurgitation/dehiscence, periannular abscess and fistula), the TTE and TEE should be evaluated in detail.3,4 Furthermore, multidetec-tor computed tomography, real time three dimensional TEE,5 and cardiac magnetic resonance are complementary diagnostic meth-ods to transthoracic echocardiography in the diagnosis of PVE and its complications such as pseudoaneurysm, fistula, and periannular abscesses formation.6
In conclusion, this case report reminds all clinicians of the serious effects of fungal PVE and the key role of echocardiography in the early diagnosis.
CONFLIC T OF INTEREST
The authors declare that they have no conflict of interest.
ORCID
Ahmet Guner https://orcid.org/0000-0002-1845-1710 Macit Kalcik https://orcid.org/0000-0002-8791-4475
Ahmet Guner MD1 Macit Kalcik MD2 Mehmet Ozkan MD1,3 1Department of Cardiology, Kosuyolu Kartal Heart Training and
Research Hospital, Istanbul, Turkey 2Department of Cardiology, Faculty of Medicine, Hitit University,
Corum, Turkey 3School of Health Sciences, Ardahan University, Ardahan, Turkey
Correspondence Ahmet Guner, MD, Department of Cardiology, Kosuyolu Kartal Heart Training and Research Hospital, Istanbul, Turkey. Email: ahmetguner488@gmail.com REFERENCES
1. Carneiro H, Rasalingam R. Fungal prosthetic aortic valve endocar-ditis and endarteritis: an unusual cause of aortic root vegetations.
Echocardiography. 2018. https://doi.org/10.1111/echo.14233 [Epub
ahead of print].
2. Rivoisy C, Vena A, Schaeffer L, et al. Prosthetic valve Candida spp. en-docarditis: new insights into long- term prognosis- the ESCAPE Study.
Clin Infect Dis. 2018;66:825–832.
3. Habib G, Lancellotti P, Antunes MJ, et al. 2015 ESC guidelines for the management of infective endocarditis: the Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio- Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J. 2015;36:3075–3128.
4. Baddour LM, Wilson WR, Bayer AS, et al. Infective endocarditis in adults: diagnosis, antimicrobial therapy, and management of compli-cations: a scientific statement for healthcare professionals from the American Heart Association. Circulation. 2015;132:1435–1486.
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LETTER TO THE EDITOR5. Güner A, Tuncer MA, Aytürk M, Kalkan S, Özkan M. Giant vegeta-tion in mitral prosthetic heart valve endocarditis. Turk Kardiyol Dern
Ars. 2019. https://doi.org/10.5543/tkda.2018.14194 [Epub ahead of
print].
6. Yesin M, Kalçık M, Gürsoy MO, et al. Multimodality diagnosis and surgical management of prosthetic valve endocarditis complicated with perivalvular abscess formation. Am J Emerg Med. 2015;33:1715. e1–3.
