Update on the prevention, diagnosis and management of Infective Endocarditis (IE)
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1 Update on the prevention, diagnosis and management of Infective Endocarditis (IE) Dr.Ahmed Yahya Mohammed Alarhabi MD, MsC,FcUSM,FACC,MAHA Consultant Interventional Cardiologist Head of Cardiac Center HUST
2 ACC/AHA
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5 Introduction IE has the proclivity to cause complications both at the cardiac valve site and at extracardiac locations that can predispose affected patients to serious morbidity and mortality. It is for these reasons that management of IE requires a team approach, which generally includes specialists in infectious diseases, cardiovascular medicine, and cardiovascular surgery with particular expertise in IE. Thus every patient with IE should be managed in the inpatient setting of a medical center with experienced medical and surgical specialists to provide care, which often includes emergent diagnostic and surgical interventions.
6 Infective Endocarditis (IE) IE is an infection of the endothelial lining of the heart valves, mitral or tricuspid chorda tendinea, valve annulus, and aortic root. Pre-existing heart disease is found in 2/3 of the cases of left-sided IE. 1/3 patients have normal or clinically unrecognized valve disease. 3.6 to 7.0 cases/100,000 patient-years
7 Distribution of Types of IE Isolated AV IE is observed in 55-60% of cases. Isolated MV IE occurs in 25-30% of cases. IE of both valves occurs in 15% of cases. Prosthetic valve IE constitutes 10-25% of all cases of IE. Prosthetic valve IE is more common with prosthetic AV, multiple valves, and after replacement of an infected native valve Roldan CA. The Ultimate Echo Guide
8 Distribution of Types of IE Right-sided IE constitutes 5-10% of all cases. 80% TV is involved Most commonly associated with IVDU Also occurs in patients with right heart wires or catheters. What is the incidence of culture-negative endocarditis? 5-10% Roldan CA. The Ultimate Echo Guide
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10 IE Cont. Def. Acute Toxic presentation Progressive valve destruction & metastatic infection developing in days to weeks Most commonly caused by S. aureus Subacute Mild toxicity Presentation over weeks to months Rarely leads to metastatic infection Most commonly S. viridans or enterococcus
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19 Infective Endocarditis Pathogenesis Endothelial damage Platelet-fibrin thrombi Microorganism adherence
20 Pathophysiology Local destructive effects Valvular distortion/destruction Chordal rupture Perforation/fistula formation Paravalvular abscess Conduction abnormalities Purulent pericarditis Functional valve obstruction
21 Pathophysiology Embolization Clinically evident 11 43% of patients Pathologically present 45 65% High risk for embolization» Large > 10 mm vegetation» Hypermobile vegetation» Mitral vegetations (esp. anterior leaflet) Pulmonary (septic) 65 75% of i.v. drug abusers with tricuspid IE
22 Clinical Features Interval between index bacteremia & onset of sx s usually < 2 weeks May be substantially longer in early PVE Fever most common sign May be absent in elderly/debilitated pt. Murmur present in 80 85% Generally indication of underlying lesion Frequently absent in tricuspid IE Changing murmur
23 Braunwald 10 th edition, 2015
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25 Braunwald 10 th edition, 2015
26 Braunwald 8 th Edition
27 PVE commonly extends beyond the valve ring into the annulus which can cause dehiscence, paravalvular regurgitation and conduction disturbances. Braunwald 8 th Edition
28 Janeway Lesions
29 Splinter Hemorrhage
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31 Subconjunctival Hemorrhages
32 Roth s Spots
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34 Echo.Cont. TTE sensitivity Vegetation <5mm 25% Between 6-10mm 70% TEE sensitivity % Prosthetic endocarditis TEE >> TTE Evangelista Heart 90: (2004)
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38 Evangelista Heart 90: (2004) BMJ Vol. 333, Aug. 2006
39 BMJ Vol. 333, Aug Evangelista Heart 90: (2004)
40 BMJ Vol. 333, Aug. 2006
41 Subaortic Complications of AV Endocarditis
42 Braunwald 10 th edition, 2015
43 Braunwald 10 th edition, 2015
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66 Conclusions The epidemiology of IE has changed in developed countries. TEE has a 95% sensitivity in detecting vegetations and is also key in finding complications of vegetations. Moderate to severe heart failure and vegetation length are important indications for surgery. Antibiotic prophylaxis regiman for IE was updated in 2007.
67 Thank you for attention
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