ISKANDER AL-GITHMI, MD, FRCSC Consultant Cardiothoracic Surgeon Assistant Professor of Surgery King...

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.


““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.


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


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.


““Pathogenesis”Pathogenesis”

Bacterial adherence to damaged valve:

- Mechanical lesions

- Inflammatory lesions



““Diagnosis Pre-requisite”Diagnosis Pre-requisite”

High index of suspicious

Early TEE: High sensitivity 75-95% Specificity 85-98%


Duke Clinical CriteriaDuke Clinical Criteria


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


““Echocardiography in infective endocarditis”Echocardiography in infective endocarditis”

Extremely important not only to make diagnosis but for early detection of potential complications.


Major Complications

- Thrombo-embolism

- Heart Failure

- Peri-annular extension of infection and annular dehiscence


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.



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



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


““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.


““What is the time interval required for What is the time interval required for surgical intervention in infective surgical intervention in infective

endocarditis?”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.


““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.


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.


““Management Approach to Infective Management Approach to Infective Endocarditis”Endocarditis”

Surgical versus medical therapy in active complicated native valve 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


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



““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.

Date post:	13-Jan-2016
Category:	Documents
Upload:	muriel-caldwell
View:	222 times
Download:	0 times

ISKANDER AL-GITHMI, MD, FRCSC Consultant Cardiothoracic Surgeon Assistant Professor of Surgery King...

Documents