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HPI

67 caucasian male

CC: Chest pain

Chest pain was 10/10 in severity, woke him up

from sleep, dull, nonradiating No palpitations, SOB, diaphoresis, nausea or

vomiting

EMS called En route given ASA and NTG which did not

provide relief of symptoms

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PAST MEDICAL HISTORY

Aortic valve stenosis s/p aortic valve replacement(bioprosthetic) in 2011

BPH

s/p bilateral inguinal herniorrhapy

MEDICATIONS

Aspirin, Flomax, Naproxen, Flexeril NKDA

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FAMILY HISTORY (+) heart diseasegrandmother, diagnosed at age 75

SOCIAL HISTORY Married, retired employee, nonsmoker, drinks wine

occasionally

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Review of systems

No nasal congestion or sore throat

No cough or SOB

No abdo pain, nausea or vomiting

(+) Diarrhea x 2 days

No dysuria or hematuria

No weight loss or weight gain

No headache or dizziness

(+) chills but no documented fever

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Physical Exam

T-36.2, BP-94/57, HR-104, RR-20, sats 98% RA

Alert and oriented x 3

Supple neck, no lymphadenopathy

Lungs: CTAB Heart: S1S2, regular rhythm, tachycardic, no

murmur/rubs/gallops

Abdomen: soft, nontender, nondistended, bowel sounds

heard No pedal edema/cyanosis/clubbing, good peripheral

pulses

Neuro exam nonfocal

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Labs

BMP

Na 141

K 4.3

Cl 102

CO2 25

BUN 13

Crea 0.9

Glucose 92

Ca 8.6AG 14

CBC

Hb 13.1

Hct 38.9

WBC 15.7

Plt 178

Neut 78%

Lymp 9%

Trop I 0.026

INR 1.12

BNP 706

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EKG

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CXR

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Cath Report

LVEF > 60%

LMCANo obstructing lesions

LAD

No obstructing lesions LCXProximal third obtuse marginal artery

was 100% occluded

RCA

dominant to the posterior circulation.No obstructing lesions.

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Hospital Course

Concern for possible pericarditis

ESR 34, CRP 14.5

ID consulted: Suspect viral pericarditis

Influenza A and B - negative

Mycoplasma pneumoniae PCR - negative

Stool for C. Diff - negative

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Transthoracic Echo

LVEF 68%

Mild MR

Bioprosthetic aortic valve prosthesis. It is well-seated with no perivalvular regurgitation.

Mean TVG 12.68.

No evidence of pericardial effusion

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Hospital Course

Blood Culture (1stset) Prelim report

Bottle I: Gr (+) cocci in pairs and chains

Bottle II: Gr (+) organisms

ID started Gentamicin + Zyvox + Unasyn while

waiting for final blood culture report

Blood Culture (1stset) Final report

Streptococcus viridans

ID shifted Abx to Ceftriaxone + Gentamicin

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TEE

Normal LV size and systolic function with LVEF 55-60%

No evidence of thrombus in the left atrial body orappendage

No spontaneous echo contrast in the LA

Aortic valve bioprosthesis is well-seated. Novegetations, perivalvular leaks or abscessformation. No AR. No AS. MG 23. AVA 1.3.

Pericardium is normal. No significant pericardialeffusion

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Hospital Course

2ndand 3rdsets of Blood Culture also showed

growth of Strep viridans.

4thset of Blood Culture: No growth

PICC line inserted

Discharged on Ceftriaxone (6 weeks) +

Gentamicin (2-6 weeks)

Repeat TEE in 2 weeks

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Infective Endocarditis

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Physical Exam

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Blood Cultures

Should be obtained prior to antibiotic therapy

Minimum of three blood cultures

Not all organisms have the same propensity to cause endocarditis

Typical causes of IE

Staphylococcus aureus

Viridans streptococci and Streptococcus bovis Enterococci

HACEK group organisms

For an organism likely to cause endocarditis (eg, S. aureus, viridansstreptococci), twopositive samples collected more than 12 hoursapart

For an organism that is more commonly a skin contaminant,threeor a majority of four or more separate blood cultures arepositive and the first and last samples are collected at least onehour apart

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Echocardiogram

An echocardiogram should be performed in allpatients with a moderate or high suspicion of

endocarditis

TTE: relatively low sensitivity (29-63%), specificity

approaches 100%

TEE:

higher sensitivity than TTE (100% vs 63%, 94% vs 44%)

especially important for prosthetic valves in the mitral

or aortic position

more sensitive than TTE for the detection of valve

abscess (87% vs 28%)

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Echocardiogram

We generally perform a TTE as the first diagnostic testin most patients with suspected IE. However, it isreasonable to begin with TEE in selected settings: Limited transthoracic windows (eg, due to obesity, chest

wall deformity, or mechanical ventilation) Prosthetic valves, especially prosthetic aortic or mitral

valves in which shadowing may make visualization difficultby TTE

A prior valvular abnormality (including previous

endocarditis) S. aureus bacteremia

Bacteremia due to an organism known to be a commoncause of IE such as viridans streptococci

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Treatment

Empiric therapy

Should cover Staphylococcus, Streptococcus and

Enterococcus

Vancomycin 30 mg/kg per 24H IV in 2 divided

doses

Duration of therapy

2-6 weeks

Depends on organism, susceptibility, native vs

prosthetic valve

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SURGERY IN NATIVE VALVE ENDOCARDITIS

Heart failure, particularly if moderate to severe, thatis directly related to valve dysfunction

Severe aortic or mitral regurgitation with evidence of

abnormal hemodynamics such as premature closure

of the mitral valve in patients with aortic

insufficiency

Endocarditis due to fungal or other highly resistant

organisms Perivalvular infection with abscess or fistula

formation

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SURGERY FOR PROSTHETIC VALVE ENDOCARDITIS

Heart failure Dehiscenceseen by cine fluoroscopy or

echocardiography

Evidence of increasing valve obstruction orworsening regurgitation

Complications such as abscess formation

Persistent bacteremia or recurrent emboli despite

appropriate antibiotic therapy Relapsing infection

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