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PubMed1995

Antibiotic treatment of adults with infective endocarditis due to streptococci, enterococci, staphylococci, and HACEK microorganisms. American Heart Association.

OBJECTIVE: To provide guidelines for the treatment of endocarditis in adults caused by the following microorganisms: viridans streptococci and other streptococci, enterococci, staphylococci, and fastidious gram-negative bacilli of the HACEK group. PARTICIPANTS: An ad hoc writing group appointed by the American Heart Association under the auspices of the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young. EVIDENCE: Published studies of the treatment of patients with endocarditis and the collective clinical experience of this group of experts. CONSENSUS PROCESS: The recommendations were formulated during meetings of the working group and were prepared by a writing committee after the group had agreed on the specific therapeutic regimens. The consensus statement was subsequently reviewed by standing committees of the American Heart Association and by a group of experts not affiliated with the working group. CONCLUSIONS: Sufficient evidence has been published that recommendations regarding treatment of the most common microbiological causes of endocarditis (viridans streptococci, enterococci, Streptococcus bovis, staphylococci, and the HACEK organisms) are justified. There are insufficient published data to make a strong statement regarding the efficacy of specific therapeutic regimens for cases of endocarditis due to microorganisms that uncommonly cause endocarditis. As a useful aid to the practicing clinician, the writing group developed a consensus opinion regarding management of endocarditis caused by the most commonly encountered microorganisms and regarding those cases due to infrequent causes of endocarditis.

Adult↗
PubMed1995

[Reparative surgery of the mitral valve in bacterial endocarditis].

INTRODUCTION: Short and long-term results of valve repair for pure mitral insufficiency resulting from native valve endocarditis are reported in 28 consecutive patients with a mean age of 55 years (range 18-74). METHODS: Six patients had acute endocarditis, with positive blood cultures in three of them. The mean time between onset of endocarditis symptoms and operation was 23 days in patients with acute endocarditis and 4.6 years in patients with healed endocarditis. Preoperatively, 87% of the patients were in NYHA class III. Indications for operation were heart failure (24 patients) and uncontrolled sepsis (4 patients). Mitral valvuloplasty was combined with other procedures in 4 patients. There was previous underlying valve pathology in 75%. RESULTS: Mitral repair was performed according to the techniques proposed by Carpentier; in 2 cases we used an original technique consisting of a double-orifice repair. Only one patient died in the hospital (operative mortality: 3.5%). By actuarial methods 96% of the patients were alive 6 years postoperatively. During the follow-up period there was no recurrence of endocarditis and no reoperation for valvular insufficiency. Ninety-three per cent of the patients were in NYHA class I or II. CONCLUSIONS: We conclude that mitral valve repair for insufficiency resulting from bacterial endocarditis is possible in acute and healed disease, has a low operative mortality and has resulted in patients free of recurrent infection. Mitral valve repair is an attractive alternate to valve replacement in bacterial endocarditis.

Acute Disease↗
PubMed1994

[Infectious endocarditis in non-addict patients without predisposing heart disease. Differential features].

INTRODUCTION AND AIMS: Although uncommonly, infective endocarditis in non-addict patients may involve people without predisponente heart disease. The aim of our study was to assess the clinical and prognostic features of this type of endocarditis and to compare them with those of the more common type of endocarditis with underlying lesion. METHODS: With this aim, we have reviewed 71 consecutive cases of non-addict infective endocarditis diagnosed in our hospital in the last 7 years; there was no preexisting cardiac lesion in 9 patients (13% of all endocarditis and 21% of native valve endocarditis), while underlying heart disease, including mitral valve prolapse, was present in the remaining 62 patients. RESULTS: Mean age was significantly lower in 9 patients without preexistent lesion (28 +/- 18 versus 46 +/- 17 years, p < 0.01), while there was no differences for gender. Infection involved the aortic valve in 56%, the tricuspid or pulmonary valve in 33% and the mitral valve in only 11% of the patients without underlying cardiopathy (for 44%, 4% and 49%, respectively, in patients with cardiopathy). Staphylococcus aureus caused 67% of cases in patients without cardiopathy and only 9% in those with cardiopathy. Surgery was required in a similar proportion by both groups of patients (55% and 56%), although mortality was more than twice higher in patients with prior cardiac lesions (25% versus 11%). CONCLUSIONS: A significant proportion of non-addict infective endocarditis involves patients without predisponente heart disease. These cases have some differential features (younger age, aortic and right heart valves involvement, S. aureus as the main causative agent and lower mortality) in comparison to those of endocarditis in patients with underlying cardiopathy.

Adolescent↗
PubMed1994

[The usefulness of transesophageal echocardiography in the diagnosis of infectious endocarditis and its complications].

INTRODUCTION AND AIMS: Transthoracic echocardiography is a technique with high specificity but low sensitivity in the diagnosis of valvular vegetations and infectious endocarditis complications. Recent reports have shown the transesophageal technique to be more sensitive. The aim of this study was to assess the comparative diagnostic roles of transthoracic and transesophageal echocardiography in infectious endocarditis. METHODS: Eighty-eight patients with infectious endocarditis (native valve in 71 and prosthesis in 17) were studied. All underwent transthoracic echocardiogram followed by transesophageal study to detect vegetations and possible complications, particularly paravalvular abscesses. RESULTS: Transthoracic echocardiogram diagnosed vegetations in 33 (46%) of the 71 native valve endocarditis, whereas these were detected by transesophageal study in 67 (94%). In 23 patients vegetations were surgically confirmed. Transthoracic echocardiography failed to diagnose vegetations in any of the prosthetic endocarditis, whereas they were detected by transesophageal study in 11 of the 17 cases (65%). Of the 9 patients who underwent surgery in the acute phase, 5 presented vegetations on transesophageal study which were confirmed at surgery. Transesophageal echocardiography diagnosed 14 abscesses: 11 aortic peri-annular and 3 in the interfibrous. Echocardiography only detected 1 of the peri-annular aortic abscesses. All patients with peri-annular abscess underwent surgery. Transesophageal echocardiography was also more effective than transthoracic in the diagnosis of other complications: 15 vs 4 chordae tendineae mitral valve rupture and 18 vs 13 aortic valve disruption. CONCLUSIONS: Transesophageal echocardiography is more effective than transthoracic echocardiography in the diagnosis of infectious endocarditis and its complications and would therefore be indicated in all cases of absence of vegetations on transthoracic echocardiography and clinical suspicion of endocarditis. Transesophageal echocardiography could be indicated in all cases of clinically suspected aortic endocarditis to rule out peri-annular abscesses.

Adult↗
PubMed1994

[Bacterial endocarditis at a county hospital department, 1983-1992. Prognosis in relation to bacteriology, disease localization and treatment].

The case records of 69 patients with a diagnosis of bacterial endocarditis were reviewed. Forty-nine patients had native valve endocarditis (NVE) and 20 patients had prosthetic valve endocarditis (PVE). Among patients with NVE left-sided endocarditis was treated surgically more often than right-sided endocarditis. Involvement of the aortic valve was the most important indicator of death and acute/subacute surgical intervention. The mortality was 29%. No patient with right-sided endocarditis died. The infective agent did not seem to influence outcome or frequency of surgical intervention. Among patients with PVE the most frequently isolated organism was coagulasenegative staphylococci. Surgical intervention occurred most frequently in those with infection with coagulase-negative staphylococci or culture negative endocarditis. The mortality was 25%, identical for early and late cases. The patients who died were all infected with staphylococci. The localization did not seem to influence treatment or outcome. In spite of advances in surgical and medical treatment bacterial endocarditis is still a life-threatening disease with a high mortality.

Bacterial Adhesion↗
PubMed1993

[Cardiac and extracardiac abscesses in bacterial endocarditis].

Cardiac abscesses are observed in 20 to 30% of cases of infective endocarditis and in at least 60% of prosthetic valve endocarditis. The aortic valve ring is more frequently affected than the mitral valve ring. A cavity contiguous with a cardiac chamber forming a pseudo-aneurysm or a closed purulent collection, the abscess may extend to the neighbouring cardiac structures or to the ascending aorta. This extension may cause conduction defects, abnormal communications between the cardiac chambers, pericardial disease and, exceptionally, myocardial ischaemia, complications which are clinical signs of abscess formation in patients with infective endocarditis. The presence of a cardiac abscess is a poor prognostic factor in infective endocarditis. The diagnosis must be made at an early stage when surgical treatment is optimal. The most valuable investigation is transoesophageal echocardiography with a sensitivity of over 80% and a specificity of about 95%. This investigation has become practically routine in all patients with endocarditis in order to diagnose abscesses at an early stage, especially in cases of aortic or prosthetic valve endocarditis. Information about the site, size and extension of the abscess may be obtained and existing or potential complications may be envisaged with a view to surgery. Other imaging diagnostic techniques, such as angiography, CT scanning and nuclear magnetic resonance imaging have a number of disadvantages and are not more sensitive than transoesophageal echocardiography. Surgical techniques depend on the site and extension of the abscess. They are sutured or closed with dacron or pericardial patches after having been cleaned and filled with formulated resorcin glue. The valvular prosthesis is inserted either in anatomical position or in a sub or supracoronary dacron tube necessitated by the perivalvular extension of the infectious lesions. These complex procedures may require associated coronary reimplantation or revascularisation when the coronary ostia are affected. The highest operative mortality is observed in prosthetic valve endocarditis with abscess and extra-annular prosthetic implants. The risk of secondary valvular dehiscence, often recurrent, is much higher when there is an abscess at operation. Extracardiac abscesses in cases of infective endocarditis are mainly observed in the cerebral and/or splenic territories. They may become the main problem, especially cerebral abscesses, but they rarely require surgery.

Abscess↗
PubMed1995

[Surgical therapy of acute tricuspid valve endocarditis: indications, technique and results].

Tricuspid valve endocarditis is treated by antibiotics alone in the majority of the cases. However, intractable infection or hemodynamic compromise may warrant surgery. In those cases total valve-excision or valve-replacement had been the most common surgical procedures. Both are controversial in regards to the hemodynamic consequences and to the long-term prognosis. In the following, results of tricuspid valve repair in acute infective endocarditis are reported and discussed as an additional treatment option. Between January 1988 and December 1993, 118 patients were operated for acute valve endocarditis at our institution. Eleven of these patients had tricuspid valve endocarditis, isolated (n = 7) or combined with endocarditis of a left-sided valve (n = 4). In the cases with isolated tricuspid valve endocarditis, the indication for surgery was intractable infection in 6 and hemodynamically relevant tricuspid-insufficiency in 1 out of 7 patients, respectively. In all patients with associated left-sided endocarditis, the indication was hemodynamic deterioration. In 8 patients the tricuspid valve endocarditis was treated as follows: Debridement, vegectomy, patch-reconstruction of the cusps, bicuspidalization. In 3 patients reconstruction was not possible because of extended involvement of all parts of the valve, including the valve ring and the papillary muscles. In these patients, primary valve-replacement (n = 1) or valve-excision with secondary replacement (n = 2) was performed. In 4 patients tricuspid-reconstruction was combined with mitral- (n = 1), aortic- (n = 1) or double-valve replacement (n = 2).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed2000

Endocarditis in the Pediatric Population.

Endocarditis is a rare, but potentially fatal process in children. Patients with congenital heart disease compose the majority of patients with endocarditis. Neonates and children with central venous catheters are an increasingly frequent group of patients diagnose with this disease. Rheumatic fever predisposing to endocarditis is unusual. Streptococcus viridans and Staphylococcus aureus are the most pervasive organisms associated with endocarditis, though others are becoming more frequent. Blood cultures should be obtained in febrile children with congenital heart disease before the administration of antibiotics. Echocardiography is useful in children with known endocarditis, and in children in whom there is a high level of clinical suspicion for endocarditis. Echocardiography is a poor screening tool for patients without clinical or bacteriologic evidence for endocarditis. Endocarditis prophylaxis for children with congenital heart disease (excluding a secundum atrial septal defect) before appropriate procedures is recommended.

Journal Article↗
PubMed2003

Treatment of destructive aortic valve endocarditis with the Freestyle Aortic Root Bioprosthesis.

BACKGROUND: Successful treatment of destructive aortic valve endocarditis with annular abscess formation requires extensive surgical debridement and reconstruction of the left ventricular outflow tract and aortic root. Homograft aortic roots are the conduits of choice, but because they are not available in all cases, alternative conduits are needed. METHODS: Owing to its features, which are comparable to those of homografts, the Freestyle aortic root xenograft was used in 10 consecutive patients aged between 32 and 77 years. All patients had extensive abscess formation, 5 presented with prosthetic valve endocarditis, 2 had additional mitral valve endocarditis requiring partial leaflet resection and reconstruction, 1 patient had an additional fistula into the right atrium, and 1 required coronary bypass. One patient developed a septic ventricular septal defect and fistula into the right atrium with tricuspid valve endocarditis. RESULTS: None of the patients required reoperation for bleeding. Two (20%) patients died in the postoperative period, 1 due to multiorgan failure, and 1 due to preexisting invasive pulmonary aspergillosis. At autopsy, neither had evidence of intrapericardial hematoma or suture dehiscence. One patient died 13 months postoperatively without clinical signs of valve dysfunction or recurrent endocarditis. All other patients are well at 12 to 42 months after surgery. Clinical examination and echocardiography at the most recent follow-up showed no signs of valve dysfunction, recurrent fistulation, or endocarditis. CONCLUSIONS: The Freestyle aortic root appears to be an acceptable alternative to homografts in the treatment of severe endocarditis. Long-term valve durability in younger patients, however, remains to be determined.

Adult↗
PubMed1989

Septic peripheral embolization from bacterial and fungal endocarditis.

Arterial embolization is second only to cardiac failure as a potentially lethal complication of acute infectious endocarditis. Embolization may be encountered with increasing frequency due to the prolongation of life afforded by antibiotics and cardiac valve replacement surgery. While distal organs are more often affected, peripheral embolization of the lower extremities is by no means rare. Over a two-year period, we have treated six patients with acute infectious endocarditis who developed lower extremity ischemia. Four patients had Gram positive bacterial endocarditis while two immunosuppressed patients developed fungal endocarditis. Treatment of all six patients included lower extremity embolectomy or bypass grafting and long-term intravenous antimicrobial or antifungal therapy. Cardiac valve replacement was required in all six patients. All lower extremities were successfully reperfused, and no patient required amputation. Although the four patients with bacterial endocarditis survived, the two patients with fungal endocarditis eventually died. In conclusion, aggressive use of arteriography, embolectomy, antimicrobial drugs, and cardiac valve replacement appear to offer the best chance for survival and limb salvage for arterial embolism related to endocarditis.

Adult↗
PubMed1995

Hospital-acquired infectious endocarditis not associated with cardiac surgery: an emerging problem.

To assess the most relevant features of hospital-acquired endocarditis, we conducted a retrospective study of cases of infectious endocarditis at a single university hospital from 1978 through 1992. During this period 248 episodes of infectious endocarditis were documented; 23 (9.3%) of these episodes were hospital-acquired and were not associated with cardiac surgery. (This figure represented a remarkable rise in the frequency of nosocomial endocarditis, only one case of which was identified among 101 cases of endocarditis treated at the same institution between 1960 and 1975.) In each of the 23 nosocomial cases, endocarditis was the result of bacteremia associated with a hospital-based procedure: intravenous catheterization (15 cases), instrumentation of a diseased urogenital tract (seven cases), or liver biopsy (one case). Staphylococcus aureus and Enterococcus faecalis were the predominant organisms isolated from intravenous catheters and the urogenital tract, respectively. Two of seven enterococcal isolates were highly resistant to gentamicin (MIC, > 2,000 micrograms/mL). Overall mortality was 56%. Two subsets of at-risk patients with different anatomic and clinical manifestations were identified. Our results emphasize that infectious endocarditis must be considered a serious nosocomial hazard against which preventive measures must be implemented.

Bacteremia↗
PubMed2006

Culture-positive and culture-negative endocarditis in patients with cancer: a retrospective observational study, 1994-2004.

Endocarditis is uncommon in patients with cancer. The characteristics of culture-positive (CPE) and culture-negative endocarditis (CNE) in high-risk cancer patients are not known; therefore we sought to evaluate the disease characteristics in patients with endocarditis at a comprehensive cancer center. We retrospectively reviewed the transthoracic (TTE) and transesophageal (TEE) echocardiograms obtained from 654 consecutive cancer patients in whom endocarditis was suspected between 1994 and 2004. Endocarditis was confirmed in 45 (7%) of 654 patients using modified Duke University criteria based on information obtained from hospital records and computerized data systems. In 21 (95%) of 22 cases, TEE examinations were diagnostic, and 16 (42%) of 38 patients with initially nondiagnostic TTE studies had the diagnosis confirmed by TEE study; this difference between diagnostic TEE and initial nondiagnostic TTE was significant (p < 0.0001). Among the 26 (58%) patients with CPE, Staphylococcus aureus (35%) was the most common organism isolated, followed by coagulase-negative Staphylococcus species (23%). Eighteen (78%) of 23 patients with a central venous catheter had CPE, whereas only 8 (36%) of 22 patients without a central venous catheter had CPE (odds ratio [OR], 6.3; 95% confidence interval [CI], 1.69-23.53; p < 0.006). Vegetations were larger in patients with CPE than in patients with CNE (median +/- standard deviation, 10 +/- 8.8 vs. 8.7 +/- 3.9 mm). Fifteen patients (58%) with CPE and 10 (53%) with CNE had embolic complications. We note that cutaneous and septic pulmonary emboli were more common in patients with CPE than in patients with CNE (31% vs. 11% and 15% vs. 0%, respectively), whereas embolic cerebrovascular and fatal embolic coronary events were more common in patients with CNE than in those with CPE (37% vs. 12% and 21% vs. 0%, respectively; p = 0.026). The 4-week endocarditis-attributable death rate did not differ significantly between the groups (CPE, 15% vs. CNE, 32%; p = 0.28). On stepwise multivariate regression analysis, patients with neutropenia (OR, 22.52; 95% CI, 2.25-225.48; p < 0.008) and those with embolic cerebrovascular events (OR, 17.07; 95% CI, 1.63-178.45; p < 0.01) had an increased probability of death due to endocarditis. The clinical spectrums of CPE and CNE differed in these patients with cancer. In patients with CNE, embolic cerebrovascular and fatal myocardial infarction were relatively common.

Adolescent↗
PubMed1983

Endocarditis in high-risk neonates.

The clinical spectrum of neonatal endocarditis, including bacterial and nonbacterial types, is examined in five case reports that were drawn from nursery experiences over a recent 2-year period. In contrast to previous reports of 100% mortality from neonatal endocarditis, one patient survived. Changing heart murmur and hematuria were most frequently associated with bacterial and nonbacterial endocarditis in four of the five cases. Pulmonary hypertension, thrombocytopenia, and coagulopathy were also associated with nonbacterial endocarditis. Echocardiograms were performed on four of the patients; only one was suggestive of endocarditis. Staphylococcus aureus was isolated from both cases of bacterial endocarditis, including the single survivor. Thus, it is suggested that the initial antibiotic coverage of any neonate with the clinical syndrome of sepsis, hematuria, and a heart murmur include antistaphylococcal coverage for the possibility of bacterial endocarditis.

Echocardiography↗
PubMed1982

Culture-negative endocarditis.

Etiologic factors in culture-negative endocarditis--better referred to as "apparent" culture-negative endocarditis--include (1) previous antibiotic therapy, (2) fastidious, slow-growing bacteria, (3) nonbacterial organisms, (4) right-sided endocarditis, and (5) noninfective endocarditis. Patients with apparent culture-negative endocarditis are more likely to have had prior antimicrobial therapy and to experience major emboli than are patients with endocarditis whose blood cultures are positive within 48 hours. The literature suggests that survival of patients with apparent culture-negative endocarditis is 92% if fever responds to therapy within 1 week but only 50% if they are still febrile after 1 week of therapy. Guidelines for diagnosis and therapy are outlined.

Anti-Bacterial Agents↗
PubMedDate not supplied

Surgery for aortic valve endocarditis.

From March 1994 to March 1997, 36 patients with aortic valve endocarditis were managed surgically. Of these, 30 patients had native valve endocarditis and six had prosthetic valve endocarditis. In patients with native valve endocarditis, surgical procedures included aortic valve repair (n=6), homograft aortic valve replacement (n=9), Ross procedure (n=5) and prosthetic aortic valve replacement (n=10). There were three early and two late deaths in this group. In patients with prosthetic valve endocarditis, aortic valve replacement with a homograft was performed in all. Active infection and prosthetic valve endocarditis were the most important predictors of early mortality. The availability of a homograft valve provides an alternative to prosthetic valve replacement in patients with aortic valve endocarditis.

Adolescent↗
PubMed1987

Staphylococcus aureus bacteremia. Clinical, serologic, and echocardiographic findings in patients with and without endocarditis.

Seventy-two adult patients with Staphylococcus aureus bacteremia were prospectively studied clinically, serologically, and echocardiographically. Multivariate analysis identified four parameters that significantly predicted endocarditis in staphylococcemic patients at time of initial evaluation: absence of a primary site of infection; community acquisition of infection; metastatic sequelae; and valvular vegetations detected by echocardiography. Echocardiography was most predictive of endocarditis in patients with community-acquired S aureus bacteremia from an obvious primary focus. In 11 (69%) of 16 patients with endocarditis and vegetations on two-dimensional echocardiography, this technique also revealed other important findings, including ventricular dilatation, and/or underlying valvular lesions. In 18% of patients with S aureus bacteremia without stigmata of endocarditis, echocardiography provided information that led to a diagnosis of endocarditis and a subsequent change in therapy. Our findings support the routine use of two-dimensional echocardiography in all cases of community-acquired S aureus bacteremia to identify occult endocarditis in patients without classic stigmata of disease, and to provide important prognostic data in clinically apparent endocarditis.

Adult↗
PubMed2004

Infective endocarditis in patients with end-stage renal disease: clinical presentation and outcome.

BACKGROUND: Infective endocarditis is a common complication of vascular access in patients undergoing long-term hemodialysis. However, available data are either dated or gathered from small samples. The goal of this study was to investigate the clinical characteristics and outcome of infective endocarditis occurring in patients with end-stage renal disease. METHODS: Patients were identified by computerized discharge diagnosis and manual chart review at 3 major hospitals in Honolulu, Hawaii. The search covered an 11-year period, through December 2001. Modified Duke criteria were retrospectively applied. Patients fulfilling criteria for definite endocarditis were included in this study. RESULTS: Forty patients were identified. Average age was 59.4 years, and average duration of hemodialysis before endocarditis was 3.3 years; arteriovenous fistulas were the most commonly used access sites. Predominant organism was Staphylococcus aureus in 20 (50%) of the 40 cases. The mitral valve was affected in 29 cases (73%); aortic and mitral valve endocarditis was seen in 8 cases (20%). Overall in-hospital mortality was 52% (21/40). Patients with an unfavorable outcome more often had fever on admission, fewer negative blood cultures, and bivalvular infective endocarditis, and more often underwent valve replacement surgery. The perioperative mortality in patients undergoing valve replacement was 73% (11/15). CONCLUSIONS: Mortality of infective endocarditis in patients with end-stage renal disease remains high and has been essentially unchanged during the past decade. If patients require valve replacement surgery, mortality is even higher. A randomized, controlled trial is needed to clarify whether the increased mortality is due solely to more severe disease in patients requiring valve replacement surgery.

Anti-Bacterial Agents↗
PubMed1998

Thirty-year incidence of infective endocarditis after surgery for congenital heart defect.

CONTEXT: The incidence of infective endocarditis after surgical repair of congenital heart defects is unknown. OBJECTIVE: To determine the long-term incidence of endocarditis after repair of any of 12 congenital heart defects in childhood. DESIGN: Population-based registry started in 1982. SETTING: State of Oregon. PARTICIPANTS: All Oregon residents who underwent surgical repair for 1 of 12 major congenital defects at the age of 18 years or younger from 1958 to the present. MAIN OUTCOME MEASURE: Diagnosis of infective endocarditis confirmed by hospital or autopsy records. RESULTS: Follow-up data were obtained from 88% of this cohort of 3860 individuals through 1993. At 25 years after surgery, the cumulative incidence of infective endocarditis was 1.3% for tetralogy of Fallot, 2.7% for isolated ventricular septal defect, 3.5% for coarctation of the aorta, 13.3% for valvular aortic stenosis, and 2.8% for primum atrial septal defect. In the cohorts with shorter follow-up, at 20 years after surgery the cumulative incidence was 4.0% for dextrotransposition of the great arteries; at 10 years, the cumulative incidence was 1.1% for complete atrioventricular septal defect, 5.3% for pulmonary atresia with an intact ventricular septum, and 6.4% for pulmonary atresia with ventricular septal defect. No children with secundum atrial septal defect, patent ductus arteriosus, or pulmonic stenosis have had infective endocarditis after surgery. CONCLUSION: The continuing incidence of endocarditis after surgery for congenital heart defect, particularly valvular aortic stenosis, merits education about endocarditis prophylaxis for children and adults with repaired congenital heart defects.

Adolescent↗