Aortic valve endocarditis in an acutely rejecting orthotopic heart transplant recipient

Infective endocarditis following orthotopic heart transplantation: 10 cases and a review of the literature

BACKGROUND

Infective endocarditis is a known complication of cardiac transplantation. However, published information has been limited to case reports and small case series.

METHODS

Cardiac transplantation has been performed at Temple University Hospital since 1983. We identified transplant patients with ICD-9 codes for endocarditis or bacteremia. A diagnosis of endocarditis required fulfillment of the Duke criteria and presence of a vegetation. Clinical and microbiologic data were collected. Demographic and survival information were compared with heart transplant recipients without endocarditis. We reviewed all previously published cases using a MEDLINE search.

RESULTS

Ten of 659 heart transplant recipients had endocarditis (1.5%, 187 cases per 100,000 person years). Mitral and tricuspid valves were involved predominantly. No patient had aortic valve infection. Patients with tricuspid valve infection had a greater median number of endomyocardial biopsies (n=23) than those with mitral valve infection (n=9, P=0.10). The major pathogens were Staphylococcus aureus (4 cases) and Aspergillus fumigatus (3 cases). Factors associated with S. aureus infection were new hemodialysis catheters, cellulitis, and a contaminated donor organ. All patients with A. fumigatus had antecedent cytomegalovirus viremia and disseminated fungal infection, including endophthalmitis. Endocarditis-related mortality was 80%. Median survival after transplant was 1.4 years in patients with endocarditis, compared with 9.3 years in other heart transplant recipients (P<0.001).

CONCLUSIONS

Endocarditis is substantially more common in heart transplant recipients than in general populations. Frequent central venous catheter access and multiple endomyocardial biopsies appear to predispose to infection. Aspergillus is a common pathogen and endocarditis follows infection elsewhere. The prognosis of post-cardiac transplant endocarditis is poor.

Infections in the heart transplant recipient

The overall incidence of infection after transplantation has decreased with improved immunosuppressive agents, increased knowledge and use of prophylaxis, and better detection and treatment of infection. Nevertheless, infection continues to be a major cause of morbidity and mortality in heart transplant recipients. The knowledgeable nurse in any setting who cares for a transplant recipient must be aware of the lifelong susceptibility to common and opportunistic infections. The transplant recipient and his or her family must also be aware of the risks of early opportunistic infection. Infection is a lifelong concern for all persons on immunosuppressant medications, and the individual must learn appropriate precautions to reduce this risk. Hand washing and avoidance of infected individuals are the most important self-care actions that the transplant patient should adopt. Recipients must also learn to monitor for subtle signs of infection. The nurse is responsible for teaching self-care to patients and family members. Ultimately, a team effort by the patient, family, nurses, and physicians can reduce the risk of infection in this vulnerable population.