Women and Heart Disease
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Endocarditis Prophylaxis for Mitral Valve Prolapse PatientsAccording to Dawn Calderon, DO, Attending Cardiologist and Co-Director, Center for Adults with Congenital Heart Disease, Deborah Heart and Lung Center, one of the most common cardiac conditions among young, otherwise healthy women is mitral valve prolapse. The most common presenting symptom is palpitations. The vast majority of symptomatic patients can be successful treated with beta blockers. This condition can also be associated with varying degrees of valve regurgitation, and, in a small minority of cases, surgery to repair or replace the mitral valve may be required. But, states Dr. Calderon, what may silently affect more MVP patients in their daily lives is their increased risk of bacterial endocarditis, during minor surgical or dental procedures. Bacterial endocarditis, a potentially life-threatening infection of the heart valves, causes substantial morbidity and mortality despite diagnostic and therapeutic advances. Primary prevention of endocarditis is essential. Inappropriate use of antibiotic prophylaxis for MVP patients can be detrimental. Endocarditis needs to be prevented, but antibiotic overuse can lead to the development of antibiotic-resistant strains of bacteria. As a result, physicians at Deborah Heart and Lung Center are often faced with the following questions from referring physicians: “Which MVP patients should be prescribed antibiotic endocarditis prophylaxis?” and, “For which procedures should it be prescribed?” “When considering the use of antibiotic endocarditis prophylaxis, Deborah Heart and Lung Center cardiologists adhere to the guidelines set forth by the Amercian Heart Association and the American College of Cardiology,” said Dr. Calderon. “These guidelines separate patients into categories of high, moderate and negligible risk for developing bacterial endocarditis, and clearly define procedures for which prophylaxis should be prescribed.” |
Most MVP patients are at negligible or moderate risk of developing endocarditis. The AHA/ACC guidelines define negligible risk as “not higher than in the general population,” therefore not requiring prophylaxis. According to the guidelines, patients whose valves prolapse without leaking are at negligible risk. Mitral valve prolapse patients at moderate risk are patients with MVP associated with any leaking, thickening or degeneration of the mitral valve, and should receive prophylaxis prior to undergoing procedures that put them at risk of bacteremia (bacteria in the blood). More specifically, patients with prolapsing and leaking mitral valves, as identified on physical and Doppler- echocardiographic examination, should receive endocarditis prophylaxis. Thickened valve leaflets are an indication for prophylaxis, as is the presence of myxomatous degeneration of the mitral valve. Qualifying patients should receive prophylaxis prior to dental procedures associated with significant bleeding, such as periodontal surgery, dental extractions, scaling, root planing, probing, implant placement or reimplantation of avulsed teeth, initial placement of orthodontic bands, subgingival placement of antibiotic fibers or strips, endodontic instrumentation or surgery only beyond the apex, intraligamentary local anesthetic injections, or professional teeth cleaning where bleeding is anticipated. Respiratory tract related procedures, including tonsillectomy, andenoidectomy, rigid bronchoscopy and surgical operations involving respiratory mucosa, should be preceded by prophylaxis. |
For gastrointestinal procedures, such as sclerotherapy for esophageal varices, esophageal stricture dilation, endoscopic retrograde cholangiography with bilary obstruction, bilary tract suregery and surgical operations that involve intestinal mucosa, prophylaxis is recommended for moderate risk patients. “Though endocarditis prophylaxis for mitral valve prolapse patients in certain situations has been debated, physicians questioning when and for whom to prescribe antibiotics can refer to the American College of Cardiology and American Heart Association guidelines with confidence,” explained Dr. Calderon. “By classifying MVP patients into a risk category, and by prescribing to patients in the moderate- or high-risk categories, you can prevent antibiotic overuse or adverse reactions in patients who don’t need prophylaxis, and protect those at risk from a potentially life-threatening infection.” |
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