Prosthetic Valve Endocarditis: The Surgical Challenge of Double Replacement

Clinical context and challenges of multivalvular PVE

Prosthetic valve endocarditis (PVE) remains a critical pathology, with hospital mortality rates ranging between 15 and 30%. This clinical complexity increases in cases of multivalvular involvement, where operative risk is exacerbated by the necessity for complete prosthetic debridement. This case report focuses on a 69-year-old patient with a history of mitral annuloplasty, presenting with acute multivalvular PVE complicated by Staphylococcus aureus bacteremia and multifocal systemic emboli (cerebral and splenic).

Objective and diagnostic strategy

The objective of this study is to describe the urgent surgical management of a PVE combining large mobile mitral vegetations with severe valvular insufficiencies (grades III-IV) of both the mitral and aortic valves. The case illustrates the clinical application of the ESC 2023 modified Duke criteria to establish a definitive diagnosis in a context of progressive cardiac decompensation.

Therapeutic hypotheses

The authors argue that radical and early surgical intervention is essential. The approach is based on the hypothesis that total excision of the infected material (annuloplasty ring), complete debridement of vegetations, and double biological valve replacement, followed by targeted vancomycin antibiotic therapy, constitute the only way to stabilize patients at high embolic risk. This report highlights the pivotal role of the "Endocarditis Team" in the management of these complex cases.

Design and management protocol

This case report documents the urgent surgical management of a complex multivalvular infective endocarditis (IE) in a single patient. The methodological approach follows the standardized diagnostic and therapeutic pathway for high-risk prosthetic valve pathologies.

• Subject: A 69-year-old male with a history of mitral annuloplasty, admitted for progressive heart failure and recurrent fever.
• Diagnostic criteria: The diagnosis of definite IE was established according to the Duke criteria modified by the ESC 2023, integrating clinical, microbiological, and imaging data.
• Diagnostic evaluation:
  • Imaging: Echocardiography identifying mobile mitral vegetations, mitral regurgitation (grade III–IV) and aortic regurgitation (grade III–IV).
  • Microbiology: Blood cultures positive for Staphylococcus aureus.
  • Embolic work-up: Identification of cerebral and splenic infarcts by systemic imaging.
• Surgical protocol: Urgent reintervention including complete excision of the infected annuloplasty ring, radical debridement of all vegetations, and a double biological valve replacement.
• Paramètres opératoires : Temps de circulation extracorporelle (CEC) de 185 minutes et temps de clampage aortique de 135 minutes.
• Therapeutic follow-up: Targeted postoperative administration of vancomycin for a duration of 4 weeks, with monitoring of the normalization of inflammatory markers and echocardiographic evaluation of prosthetic function.

Clinical data and microbiological profile

The patient, a 69-year-old male with a history of mitral annuloplasty, presented with a definite infective endocarditis (IE) according to the Duke criteria modified by the ESC (2023). Blood cultures identified Staphylococcus aureus as the causative pathogen. Systemic embolic complications were multifocal, including cerebral and splenic infarcts.

Echocardiographic evaluation

Echocardiography revealed severe multivalvular involvement characterized by:

• The presence of large mobile mitral vegetations.
• Grade III–IV mitral regurgitation (MR).
• Significant grade III–IV aortic insufficiency (AI).

Operating parameters and surgical management

The urgent surgical intervention consisted of a complete excision of the infected annuloplasty ring, radical debridement of all vegetations, and a double biological valve replacement (mitral and aortic).

Operating parameter	Measured value
Temps de circulation extracorporelle (CEC)	185 minutes
Aortic clamping time	135 minutes
Postoperative antibiotic treatment	4 weeks (targeted Vancomycin)

Clinical outcome and follow-up

The postoperative course was marked by complete clinical stabilization. Inflammatory markers normalized at the end of the four-week antibiotic treatment. The final echocardiographic control confirmed satisfactory prosthetic function, allowing the patient's discharge in a stable condition.

Management analysis

This case highlights the extreme danger of multivalvular prosthetic valve endocarditis (PVE), a condition where hospital mortality typically exceeds 15-30%. The aggressiveness of Staphylococcus aureus, coupled with the embolic potential of mobile vegetations, justified an immediate surgical strategy in this instance, in accordance with the 2023 ESC guidelines. Success relies on exhaustive prosthetic debridement: the total removal of the infected annuloplasty ring was an essential prerequisite for the eradication of the bacterial focus.

Bien que les temps de clampage et de CEC soient prolongés, l'issue favorable confirme que l'approche agressive, bien que risquée, reste le gold standard face à une PVE multivalvulaire avec complications emboliques. La limite intrinsèque de cette étude reste son format (n=1), ne permettant pas de généraliser les taux de survie, mais elle valide l'efficacité d'une "Endocarditis Team" multidisciplinaire pour coordonner le timing chirurgical et l'antibiothérapie ciblée de longue durée.

Summary of results

This clinical case reports the success of an urgent reoperation in a 69-year-old patient with multivalvular prosthetic Staphylococcus aureus endocarditis and systemic emboli. The procedure consisted of a double biological valve replacement and complete prosthetic debridement (clamping: 135 min), followed by four weeks of targeted vancomycin, resulting in biological normalization and stable cardiac function at discharge.

In concrete terms, for the practitioner:

• Diagnostic rigor: Use the Duke criteria modified by the ESC 2023 to identify early cases of prosthetic valve endocarditis, particularly in patients with valvuloplasty rings.
• Operative indication: Faced with large mobile mitral vegetations associated with an embolic risk, immediate radical debridement is imperative to reduce hospital mortality, estimated between 15 and 30%.
• Care pathway: Manage these complex cases via a multidisciplinary "Endocarditis Team" to coordinate reintervention surgery and prolonged antibiotic therapy.

Prosthetic valve endocarditis (PVE) remains one of the most formidable challenges in cardiac surgery, with hospital mortality rates ranging between 15% and 30%. The risk intensifies drastically in cases of multivalvular involvement requiring urgent reoperation. This clinical case, reported by the Georgian Medical Journal in August 2026, illustrates the successful double valve replacement in a patient heavily impacted by a Staphylococcus aureus infection.

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