Case Studies in Complex Endocarditis Vera H. Rigolin, MD Professor of Medicine Northwestern University Feinberg School of Medicine Medical Director, Echocardiography Laboratory Northwestern Memorial Hospital Chicago, Illinois President-Elect, American Society of Echocardiography Disclosures None that pertain to this presentation 1
History 28 yr old female with history of IVDU April 2016: Pt c/o fever, cough, chills, chest pain Developed respiratory decompensation requiring intubation Blood cultures positive for staph aureus CXR suggestive of cavitary pneumonia due to septic emboli 2
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What Next? Surgery should be avoided in IVDU, if possible But, when should surgery be considered? 4
When to Operate on TV Endocarditis Right Heart Failure due to severe TR Sustained/difficult to treat infection Class IIa Tricuspid veg >20 mm and recurrent PE despite Abx Baddour, L.M., et al., Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association. Circulation, 2015. 132(15): p. 1435-86. Habib, G., et al., 2015 ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J, 2015. 36(44): p. 3075-128. What type of valve? Mechanical prosthesis Bioprosthesis Valvectomy Annuloplasty - Class 1 (when feasible) Other Options? 5
CoreMatrix ECM Small Intestine Anatomy LUMEN Submucosa Courtesy of James Cox, MD Small Intestine Submucosa (S.I.S.) CorMatrix ECM De-Cellularization A Live Stem-Cell Scaffold Courtesy of James Cox, MD 6
CorMatrix ECM A Live Stem-Cell Scaffold Courtesy of James Cox, MD CorMatrix ECM Attracts Host s Stem Cells Courtesy of James Cox, MD 7
The (Tubular) CorMatrix ECM Valve DRY WET Courtesy of James Cox, MD Courtesy of Chris Malaisrie, MD Intra-op TEE 8
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Operative Findings A large vegetation on the posterior leaflet of the tricuspid valve. Small vegetation on the anterior leaflet, which has destroyed its integrity. TV specimen Courtesy of Chris Malaisrie, MD 10
Valve seating Courtesy of Chris Malaisrie, MD Papillary muscles on the inside of the tube Courtesy of Chris Malaisrie, MD 11
Annular alignment Courtesy of Chris Malaisrie, MD Unclamped, heart-beating Courtesy of Chris Malaisrie, MD 12
Post- Bypass 13
Pre-discharge Echo 14
TV Mean Gradient: 2 mmhg (HR 70 bpm) 15
Follow-up December 2016: Resumed using IV drugs in August, 2016 One week prior to admission: needle broke in her arm C/o fever, chills, nausea, emesis, chest pain Blood Cx; Staph aureus Chest CT c/w septic emboli 16
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Mean TV Gradient: 5 mmhg (HR-=126 bpm) Journal of Thoracic and(j Thorac Cardiovasc Surg 2014;148:3042-8) 12 surgeons performed 19 TV operations 16 pts with endocarditis: 11 active, 5 treated No deaths, no heart block 2 cases of disrupted papillary attachments. Both successfully repaired 1 recurrent papillary detachment at 13 and 22 months. Treated with pericardial valve Fungal infection in one pt 2 nd cylinder implanted LONG TERM FOLLOWUP: ALL WITH NO TO MILD TR 13 PTS AT 1-2 MONTHS 8 PTS AT 6 MONTHS 3 PTS AT 12-18MONTHS 18
History Case 2 35 yr old male with h/o poor dentition, tobacco abuse who presents with 6 wks of fever, chills, SOB, drenching sweats and chest pain Former paramedic He and his friends would periodically start IVs on themselves for hydration after a night out 19
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Multiple peripheral emboli to the brain, coronaries Troponin 6.01 Blood cultures positive for strep viridans 25
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Operative Findings Large vegetation on the non-coronary cusp. Aortic valve was bicuspid. Large hole in the non-coronary cusp. Aortic root abscess between the noncoronary annulus and the base of the anterior leaflet of the mitral valve. 28
Risk Factors for Embolization Emboli can occur before diagnosis, during therapy, or after therapy completed Most emboli occur within the first 2 to 4 weeks of antimicrobial therapy Risk factors associated with embolic risk: vegetation size >10 mm and mitral valve involvement. Staphylococcal or fungal IE carry high rate of embolization independent of vegetation size. Clinical and echo features that suggest the need for surgery Vegetation Persistent vegetation after embolization Anterior mitral leaflet vegetation, particularly >10 mm >1 embolic events during first 2 wks of Abx Increase in vegetation size despite Abx Valvular dysfunction Acute AR or MR with signs of ventricular failure Heart failure unresponsive to medical therapy Valve perforation or rupture Perivalvular extension Valvular dehiscence, rupture or fistula New heart block Large abscess or extension of abscess despite Abx Circulation. 2015;132:00-00 29
Thank You 30