Strategies for the Optimal Management of Prosthetic Valve Infective Endocarditis

Abstract

Background: Prosthetic valve infective endocarditis (PVIE) remains one of the most severe and challenging forms of endocarditis, characterized by high mortality, increasing diagnostic complexity, and evolving epidemiological patterns. Recent studies demonstrate rising incidence associated with transcatheter aortic valve implantation (TAVI), a greater burden of Staphylococcus aureus, and the emergence of new or re-emerging pathogens. Advances in imaging modalities and updated diagnostic criteria have strengthened the identification of peri-valvular complications, valve dysfunction, and atypical presentations. Additionally, growing evidence supports expanded therapeutic strategies, including suppressive antimicrobial therapy in patients who are not candidates for surgery. Methods: This narrative review synthesizes findings from recent clinical studies, systematic reviews, and observational analyses focused on PVIE, including pediatric and adult populations, TAVI-related infections, surgical and antimicrobial approaches, epidemiological trends, and outcomes. Only the articles specified in the reference list were used for extraction and integration of data. Results: Across reviewed studies, PVIE consistently demonstrated substantial morbidity and mortality, influenced by pathogen profile, prosthesis type, and presence of peri-annular complications. Comparative analyses revealed distinct microbiological and clinical characteristics between TAVI-associated and surgically implanted prostheses. While early surgery remains essential in hemodynamic compromise or uncontrolled infection, suppressive antimicrobial therapy emerged as a viable alternative for high-risk surgical candidates, with observational evidence supporting its use in selected cases. Epidemiological investigations showed dynamic shifts in causative organisms and regional differences in incidence. Multimodal imaging improved diagnostic accuracy and facilitated earlier therapeutic decision-making. Conclusion: Optimal management of PVIE requires an individualized, multidisciplinary approach integrating early diagnosis, tailored antimicrobial therapy, and timely surgical evaluation. Emerging data support the selective use of suppressive antimicrobial therapy in non-surgical candidates, while ongoing epidemiological changes and increasing TAVI utilization demand updated diagnostic and therapeutic frameworks. Continued research is essential to refine risk stratification and improve outcomes in this high-risk population.