Apport des recommandations européennes

Transcription

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2 Apport des recommandations européennes Gilbert Habib Cardiology Department- La Timone Marseille - France Bordeaux le 28 Juin 2011

3 Infective Endocarditis: a changing disease new high-risk subgroups IVDA elderly intracardiac devices nosocomial diseases changing microbiology increasing incidence of staphylococcal IE new microorganisms (Coxiella burnetii, Bartonella spp, Tropheryma whipplei) more difficult to prevent more difficult to diagnose more difficult to treat

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6 IE: new guidelines ESC prevention 2. diagnosis 3. treatment

7 IE: new guidelines ESC prevention 2. diagnosis 3. treatment

8 Case report 1

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13 Incidence des bactériémies quotidiennes Duval X, Leport C. Lancet Infect Dis 2008 ; 8 : Adapted from Moreillon Med Mal Infect 2002 ; 32 :

14 Experimental Endocarditis Revisited Entenza et al, in press % of infected ve egetations Strain : MRSA P8 Inoculum: 1.6 n= 9 Bolus (1 ml/1 min) -2.0x10 3 CFU/rat Type of Inoculum n= 9 Continuous inf. (0.1ml/h/10h) PMo UNI Lausanne

15 Preexisting disease and risk of IE High risk Moderate risk Low risk Prosthetic heart valves Previous IE Congenital heart disease Acquired valve dysfunction Hypertrophic cardiomyopathy MVP with regurgitation and/or thickened valves Bicuspid aortic valve Isolated ASD Surgical repaired ASD, VSD, PDA Previous CABG surgery MVP without MR Innocent heart murmurs Previous Kawasaki disease Pacemakers / defibrillators ESC Guidelines Infective Endocarditis 2004

16 Preexisting disease and risk of IE High risk Moderate risk Low risk Prosthetic heart valves Previous IE Congenital heart disease Acquired valve dysfunction Hypertrophic cardiomyopathy MVP with regurgitation and/or thickened valves Bicuspid aortic valve Isolated ASD Surgical repaired ASD, VSD, PDA Previous CABG surgery MVP without MR Innocent heart murmurs Previous Kawasaki disease Pacemakers / defibrillators Prophylaxis recommended (I C) ESC Guidelines Infective Endocarditis 2004

17 Preexisting disease and risk of IE High risk Moderate risk Low risk Prosthetic heart valves Previous IE Congenital heart disease Acquired valve dysfunction Hypertrophic cardiomyopathy MVP with regurgitation and/or thickened valves Bicuspid aortic valve Isolated ASD Surgical repaired ASD, VSD, PDA Previous CABG surgery MVP without MR Innocent heart murmurs Previous Kawasaki disease Pacemakers / defibrillators Prophylaxis recommended (IIa C) ESC Guidelines Infective Endocarditis 2009

18 Cardiac conditions at highest risk of IE

19 Procedures at highest risk of IE

20 IE prevention: main changes 1. The principle of antibiotic prophylaxis when performing procedures at risk of IE in patients with predisposing cardiac conditions is maintained, but 2. Antibiotic prophylaxis must be limited to patients with the highest risk of IE undergoing the highest risk dental procedures. 3. Good oral hygiene and regular dental review are more important than antibiotic prophylaxis to reduce the risk of IE. 4. Aseptic measures are mandatory during venous catheter manipulation and during any invasive procedures in order to reduce the rate of health careassociated IE. 5. Whether the reduced use of prophylaxis is associated with a change in the incidence of IE must be evaluated by prospective studies

21 IE prevention: main changes 1. The principle of antibiotic prophylaxis when performing procedures at risk of IE in patients with predisposing cardiac conditions is maintained, but 2. Antibiotic prophylaxis must be limited to patients with the highest risk of IE undergoing the highest risk dental procedures. 3. Good oral hygiene and regular dental review are more important than antibiotic prophylaxis to reduce the risk of IE. 4. Aseptic measures are mandatory during venous catheter manipulation and during any invasive procedures in order to reduce the rate of health careassociated IE. 5. Whether the reduced use of prophylaxis is associated with a change in the incidence of IE must be evaluated by prospective studies

22 Reco ESC 2010 Une bonne hygiène dentaire et un suivi dentaire régulier sont recommandés chez les patients à risque Le piercing et les tatouages doivent être évités chez ces patients, surtout les piercings intéressant les muqueuses. Des mesures d asepsie rigoureuse sont recommandées lors de la manipulation des cathéters ou durant toute procédure invasive, afin d éviter les endocardites nosocomiales

23 CONCLUSIONS: LES ENJEUX 1. simplification 2. réduction 3. uniformisation 4. évaluation

24 IE: new guidelines ESC prevention 2. diagnosis 3. treatment

25 Case report 2

26 Case report 2 History of the disease 75 year-old woman, 2008: aortic bioprosthesis for aortic stenosis atrial flutter 2010 december 2010: unexplained fever Clinical examination no sign of CHF fever = 38 5 aortic systolic murmur 2/6 arterial pressure: 140 / 70 mmhg normal neurological examination

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29 Case report Laboratory data haemoglobin: 11 g / dl white blood cell count: 9,400 / mm 3 sedimentation rate: 40 mm CRP = 35 mg/l creatinin = 69 mg Blood cultures / serologies: negative

30 TEE

31 TEE

32 4 months later April 2011 new episodes of unexplained fever Clinical examination no sign of CHF fever = 37 aortic systolic murmur 2/6 Laboratory data haemoglobin: 10 g / dl white blood cell count: 8,400 / mm 3 sedimentation rate: 40 mm CRP = 12 mg/l Blood cultures negative

33 TEE

34 TEE

35 TEE December 20, 2010 April 8, 2011

36 TEE December 20, 2010 April 8, 2011

37 Decision 1. Consider infective endocarditis (BCNIE) 2. Initiate antibiotic therapy Vancomycin: 6 weeks Gentamycin: 2 weeks 3. Close follow-up, perform: repeat TTE / TEE TEP scan

38 PET scan

39 Follow-up under therapy no fever normal sedimentation rate, CRP, white blood cells TTE: normally functioning bioprosthesis blood cultures: negative

40 TEE

41 TEE

42 TEE

43 TEE April 8, 2011 April 21, 2011

44 Surgery performed on April 29, 2011 Surgical findings thickened aortic leaflets small aortic vegetation posterior aortic root abscess Surgical approach resection of infected tissues bioprosthetic valve replacement Valve cultures negative

45 Surgery performed on April 29, 2011 PCR of the valve identification of Bartonella henselae spp Doxycycline 200 mg/d

46 The Duke echographic criteria Durack DT Am J Med 1994 ; 96 : vegetation abscess new dehiscence of prosthetic valve

47 *TEE is not mandatory in isolated right-sided native valve IE with good quality TTE examination and unequivocal echocardiographic findings.

48 Diagnostic value of 3D echo

49 Aortic bioprosthetic abscess September 23, 2009 October 6, 2009

50 Recommendation 1: diagnosis 1) TTE is recommended as the first imaging modality in suspected IE 2) TEE is recommended in patients with high clinical suspicion of IE and a normal TTE 3) TEE should be considered in the majority of patients with suspected IE, even in case with positive TTE 4) Repeat TTE/TEE within 7-10 days is recommended in case of initially negative examination when clinical suspicion of IE remains high 5) TEE is not indicated in patients with good-quality negative TTE and low clinical suspicion of IE

51 Role of echocardiography in IE

52 IE: new guidelines ESC prevention 2. diagnosis 3. treatment

53 Case report 3

54 Case report History of the disease 52 year-old woman, march 2009 : fever and lombalgia diagnosis of spondylitis no previous known cardiac disease hospitalisation in the cardiology Department: June 4 th, 2009 Clinical examination no sign of CHF fever = 38 5 mitral systolic murmur 2/6 arterial pressure: 120 / 70 mmhg normal neurological examination

55 Case report Laboratory data haemoglobin: 8.5 g / dl white blood cell count: 11,000 / mm 3 sedimentation rate: 60 mm CRP = 136 mg/l creatinin = 60 mg Blood cultures: streptococcus bovis (group D)

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57 TEE

58 TEE

59 CT-scan imaging

60 CT-scan imaging

61 Patient case: summary normal LV and RV function, large (26 mm) mitral vegetation (A2) probable A2 perforation moderate mitral regurgitation: ERO = 28 mm² no CHF spondylitis, multiple emboli

62 1. Is early surgery necessary? 2. What is the optimal timing for surgery?

63 1. Is early surgery necessary? 2. What is the optimal timing for surgery?

64 Surgery in IE : Euro Heart Survey Tornos P Heart 2005 ; 91 : % native n = 118 PVE n = 41 Surgery performed Medical therapy only Reasons for surgery 49 % CHF: 65% persistent sepsis: 45% embolism: 20%

65 New guidelines 2009: native IE

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