From the Guidelines
The correct answer is "Valve stenosis on echocardiography." Endocarditis prophylaxis is not routinely advised for patients with valve stenosis detected on echocardiography alone. Prophylaxis is recommended for the other listed high-risk cardiac conditions: completely repaired congenital heart defects during the first 6 months after repair, left ventricular assist devices or implantable hearts, and surgical or transcatheter pulmonary artery valve or conduit placement. These other conditions carry higher risk of adverse outcomes from infective endocarditis. The current guidelines have become more restrictive, focusing prophylaxis only on patients with the highest risk of adverse outcomes from endocarditis rather than those with any valvular abnormality. Valve stenosis without other risk factors does not meet the threshold for prophylaxis according to current recommendations 1.
Key Points
- The American Heart Association (AHA) guidelines have become more restrictive, focusing on patients with the highest risk of adverse outcomes from endocarditis.
- Prophylaxis is recommended for high-risk cardiac conditions, including:
- Completely repaired congenital heart defects during the first 6 months after repair
- Left ventricular assist devices or implantable hearts
- Surgical or transcatheter pulmonary artery valve or conduit placement
- Valve stenosis on echocardiography alone does not meet the threshold for prophylaxis according to current recommendations.
- The guidelines emphasize the importance of maintaining optimal oral health and hygiene to reduce the incidence of bacteremia from daily activities, rather than relying on prophylactic antibiotics for dental procedures 1.
From the Research
Cardiac Lesions and Endocarditis Prophylaxis
- Completely repaired congenital heart defects during the 6 months after repair: according to 2, 3, endocarditis prophylaxis is not advised for completely repaired congenital heart defects during the 6 months after repair, unless they have a prosthetic valve or other high-risk conditions.
- Valve stenosis on echocardiography: 3 states that native valvular disease is no longer a target for prophylaxis, implying that endocarditis prophylaxis is not advised for valve stenosis on echocardiography alone.
- Left ventricular assist devices (LVAD) or implantable heart devices: there is no direct evidence in the provided studies to suggest that endocarditis prophylaxis is not advised for these devices, but 2 mentions that implanted prosthetic material can pave the way for cardiovascular device-related infections.
- Surgical or transcatheter pulmonary artery valve or conduit placement: 4 discusses the risk of infective endocarditis after pulmonary valve replacement, but does not explicitly state that endocarditis prophylaxis is not advised before dental procedures for these patients. However, 3 implies that prophylaxis is only recommended for high-risk groups, and it is unclear if these patients would be considered high-risk.
High-Risk Conditions
- Cyanotic congenital heart disease: 3 states that this is a high-risk condition for which endocarditis prophylaxis is recommended.
- Valvular prosthesis: 3 states that this is a high-risk condition for which endocarditis prophylaxis is recommended.
- Previous endocarditis: 3 states that this is a high-risk condition for which endocarditis prophylaxis is recommended.
- High-velocity shunts like ventricular septal defect: 3 suggests that these should be included in the at-risk congenital disease for infective endocarditis where prophylaxis should be applied.