Post on 13-Jan-2016
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ISKANDER AL-GITHMI, MD, FRCSCConsultant Cardiothoracic Surgeon
Assistant Professor of SurgeryKing Abdulaziz University
ISKANDER AL-GITHMI, MD, FRCSCConsultant Cardiothoracic Surgeon
Assistant Professor of SurgeryKing Abdulaziz University
““CHALLENGING ISSUES IN INFECTIVECHALLENGING ISSUES IN INFECTIVEENDOCARDITIS”ENDOCARDITIS”
It is of use, from time to time, to take stock, so to speak of our knowledge of a particular disease, to see exactly where we stand in regards to it, to inquire to what conclusion the accumulated facts seem to point and to ascertain in what direction we may look for fruitful investigation in the future….I propose to do this in the case of that most interesting disease known as ulcerative endocarditis.
““Endocarditis Milestones”Endocarditis Milestones”
1885 - Clinical syndrome; described by Sir William Osler.
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
1944 - Penicillin (Alexander Fleming)
1981 - Von Reyn Criteria [Persistant bacteremia, New regurgitant murmur and vascular Complications]
1994 - Duke’s Criteria proposed by Dr. Durack from Duke University.
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
““Background”Background” Despite improvement in health care and advancement in
diagnostic technology and therapy; the incidence of infective endocarditis has not decreased over the past decades.
Progressive evolution in risk factors:
- i.e. i.v. drug use
- Use of prosthetic valve
- Growing resistant micro-organisms.
Incidence of Infective endocarditis ~ 15000 to 20,000 new cases per year.
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
Infective endocarditis classifications:
Native – valve endocarditis: associated with congenital heart disease and chronic rheumatic heart disease.
Prosthetic-valve endocarditis:
1-5% of individual with infective endocarditis have PVE
Early-PVE: infection within 60 days of surgery
Late -PVE: infection 2-6 months of surgery
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
Infective endocarditis in intravenous drug user
- Common in young population
- Tricuspid valve involved in up to 50% of cases
- Predominant pathogenes usually staph aureus
Important iatrogenic risk factors for infective endocarditis - hemodialysis
- 3 times more frequent than in general population
- Predominant pathogenes is staph aureus.
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
““Pathogenesis”Pathogenesis”
Bacterial adherence to damaged valve:
- Mechanical lesions
- Inflammatory lesions
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
““Diagnosis Pre-requisite”Diagnosis Pre-requisite”
High index of suspicious
Early TEE: High sensitivity 75-95% Specificity 85-98%
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
Duke Clinical CriteriaDuke Clinical Criteria
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
Definite IEPathological criteria
Microorganisms: demonstrated by culture or histology in a vegetation,in a vegetation that has embolized, or in an intracardiacabscess, or
Patological lesions: vegetation or intracardiac abscess present, confirmedby histology showing active endocarditis
Clinical Criteria, using specific definitions listed in Table 22 major criteria or1 major and 3 minor criteria, or5 minor criteria
Possible IEFindings consistent with Ied that fall short of "Definite" but not "Rejected"
RejectedFirm alternate diagnosis for manifestation of endocarditis, or
““Management Strategies”Management Strategies”
It is multi-disciplinary and team work
- Cardiologist
- Echo Cardiologist
- Cardiac Surgeon
- Infectious Disease
- Neurologist
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
““Echocardiography in infective endocarditis”Echocardiography in infective endocarditis”
Extremely important not only to make diagnosis but for early detection of potential complications.
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
Major Complications
- Thrombo-embolism
- Heart Failure
- Peri-annular extension of infection and annular dehiscence
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
Thrombo-embolism
Rate 50%
Major 30 – 40%
Sub-clinical 10-20%
Up to 65% of embolic event involve CNS
90% of CNS embolism lodge in the distribution of middle cerebral artery.
More than 90% of embolization developed within the 1st 3 weeks of the diagnosis of infective endocarditis
The rate of embolization decreased overtime during anti-microbial therapy.
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
Relation Between EEs Patients Embolic Events Detected Vegetations Embolic Eventsand Vegetation Size (n) (%) (%) During Therapy
Lutas et. al. (3) Negative 77 22 TTE 56 ND
Positive 105 31 TTE 91 19
TEE biplane
Jaffe et. al. (16) Negative 70 43 TTE 78 16
Sanfilippo et. Al. (13) Positive 204 33 TTE 75 ND
Steckelberg et. al. (1) Negative 207* 13 TTE 38 13
Rohmann et. Al. (15) Positive 118 26 TEE biplane 42 21
Heinle et. al. (17) Negative 41 49 TTE 73 49
Positive, >20 mm 106 35 TEE biplane 92 ND
TEE monoplane (28%)
Negative 57+ 44 TTE 80 44
TEE multiplane
Present study Positive 176 37 TEE multiplane 75 9
Echocardiography
Mugge et. al. (14)
Werner et. al. (23)
De Castro et. al. (12)
Author (ref.)
Results of Previous StudiesResults of Previous Studies
Echocardiography predicts embolic events in infective endocarditis.
Study design: Prospective
Patients: 178 Consecutive patients with definite diagnosis of infective endocarditis
All had multi-plane TEE
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
Univariate
p Value p Value B Exp B 95% CI
Presence of vegetation 0.007 NS 0.06 1.07 1.01-1.13
Vegetation length <0.0001 0.03 2.05 0.37 2.28-26.57
Vegetation mobility 0.001 0.0011
Mitral valve vegetation NS NS
Aortic valve vegetation NS NS
Right valve vegetation 0.014 NS
Multiple valve vegetation NS NS
Staphylococcal IE 0.023 NS
Multivariate Analysis
CI = confidence interval; IE = infective endocarditis; NS = not significant
Results of Univariate and Multiple Stepwise Logistic Regression Analyses
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
““Clinical Implications of the Study”Clinical Implications of the Study”
The presence of vegetation visualized by echocardiogram is a predictive of embolism
The morphological characteristic of vegetations are very helpful in predicting the embolic events.
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
““What is the time interval required for What is the time interval required for surgical intervention in infective surgical intervention in infective
endocarditis?”endocarditis?”
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
Presence of vegetations is a strong indication for surgical intervention, irrespective of valve destruction, heart failure or response to anti-microbial therapy.
Embolic events is extremely high in the early stage of the disease.
Embolic events can occur up to 20% of cases from vegetation less than 10mm.
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
““Congestive Heart Failure (CHF)”Congestive Heart Failure (CHF)”
CHF may develop insidiously, despite appropriate antibiotics as a result of progressive valvular insufficiency and ventricular dysfunction.
CHF in infective endocarditis; portends a grave prognosis with medical therapy.
Delaying surgery to the point of ventricular decompensation dramatically increase operative mortality from 6% to 11% for patient without CHF, 17-33% for patient with CHF.
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
Periannular extension of infection and annular dehiscence
- Extension of infective endocarditis beyond the valve annulus predict higher mortality, more frequent development of CHF and the need for surgical intervention.
- It occurs in 10-40% of all native-valve endocarditis and 56% to 100% in PVE.
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
““Management Approach to Infective Management Approach to Infective Endocarditis”Endocarditis”
Surgical versus medical therapy in active complicated native valve infective endocarditis.
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
n % n %
CHF (Class III and IV, NYHA) 18 78 63 74 NS
Persistent Infection 11 48 29 34 NS
Persistent Systemic Hypotension 3 13 10 12 NS
Root Abscess 2 9 1 1 NS
Pericarditis 1 4 1 1 NS
CHF = congestive heart failure; NYHA = New York Heart Association; NS - not significant
p Value(23 patients)Group A Group B
(85 Patients)
Indications for Surgery (Group A) and Criteria for Inclusion in Group B
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
n % n %
Mitral 5 22 32 38 NS
Aortic 14 61 28 33 <0.05
Mitral + Aortic 4 17 19 22 NS
Mitral + Aortic + Tricuspid 0 . . . 2 2 . . .
Mitral + Tricuspid 0 . . . 3 4 . . .
Aortic + Tricuspid 0 . . . 1 1 . . .
*For group comparison, p=0.079NS=not significant; PDA=patent ductus arteriosus; VSD=ventricular septal defect
p Value(23 patients)Group A Group B
(85 Patients)
Site of Involvement by Endocarditis
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
““Conclusions”Conclusions” Despite improvement in healthcare and major advance in
the diagnostic technology as well as medical-surgical therapies, endocarditis has not decreased but new risk factors have evolved.
Treatment of this infection require a multidisciplinary approach.
Early surgery is critically important and maybe the only best option in patients with infective endocarditis irrespective of heart failure, valve destruction and response to antimicrobial therapy.
New clinical research studies should be used to provide definite answers to several remaining questions about this complex infection.