Presentation on theme: "Valve Replacement in Infective Endocarditis"— Presentation transcript:
1Valve Replacement in Infective Endocarditis PJA SlabbertCardiology
2Patient history 34 year male from NC Admitted KHC : 23/3/10 to 8/4/10 for Infective Endocarditis (culture negative)Pen G and GentamycinClinically deteriorated over 3 days and follow up echocardiogram showed:Worsening heart failureMore extensive vegetations on aorta valves
3Systemic enquiry: Previous medical Hx: Neurology: no TIA, no amurosis fugaxRespiratory: 3 weeks non productive cough, progressive dyspnoeaCardiology: Angina on exertion, ortopnea, PND, dyspnoea NYHA grade 4, ankle swelling, no sharp chest pain radiating to back.Gastro-enterology: vomited previous night.Previous medical Hx:D-E-A-T-H-, not known with cardiac condition, no chronic medication
4Examination General: Chronically ill: underweight J-A-C-C-O+L- BP 121/52 (no cardiogenic shock, wide pulse pressure), HR 92/m, normal temperature, RR 33/m, saturation 98% on 40% oxygenDiffuse fungal/ yeast skin infection:Pityriasis versicolorNo peripheral manifestations of infective endocarditis: Roth spots, subungual hemorrhages, Janeway lesions
5CardiovascularWater hammer pulse, equal pulses and BP left and right. Elevated JVP 2cm above baselineApex displaced inferior lateral: 6th ics aalLoud P2, C3 both ventriclesDecrescendo diastolic murmur parasternally with ejection systolic murmur not radiating. No Austin Flint
14Surgery in NVE Introduction 1961 : Kay and colleagues excised fungal vegetation from tricuspid valve1965 : AVR in IE due to Serratia MarcescensLast 3 decades : valve replacement/ repair common in Mx of complicated IEDecreased mortality in IE due to combination of antibiotics and timely surgical intervention
15Indications2006 American College of Cardiology/ American Heart Association (ACC/ AHA)Surgery is warranted for native valve IE who have one or more of the following1. Heart failure (moderate to severe) that is directly related to valve dysfunction.2. Severe aorta/ mitral regurgitation with evidence of abnormal hemodinamics, such as elevated LVED or left atrial pressures.3. Endocarditis due to fungal of high resistant organisms.4. Peri-valvular infection with abscess/ fistula formation
16Other condition considered as possible indications 1. Embolic events while on appropriate antibiotic regimen or large vegetations (> 10mm in diameter)2. Large vegetations > 10mm in diameter (even without embolic events) if mobile
17Choice of procedure For active infection (2006 ACC/AHA): Valve repair rather than replacementOnly possible in minority of casesThus leaflet perforation without destruction or annular involvement.
18Heart Failure Moderate to severe HF due to IE Medical therapy : mortality rate 75%Medical & surgical : mortality rate 25%HF is indication in 2/3 to ¾ of casesIE induced AR is more likely to produce HF than IE induced MR (death may occur suddenly in aorta involvement)
19Caveats Non cardiac factors that exaggerate HF Hx of previous HF. Fever, anemia, sepsis, renal insufficiencyHx of previous HF.HF out of proportion to valve dysfunction.
20Complicated infection Persistent positive BC5 to 7 days or lack of clinical improvement after 1 week of appropriate Rx search for metastatic abscess; then Echocardiographic evidence of perivalvular abcess / fistula formation/ leaflet perforationSerial TEE and early in presence of known difficult organism.New heart block
21Fungal infection is in general an early indication for Relapse after adequate therapy may require intervention. A 2nd course of antibiotics is only indicated if no perivalvular infection and offending organism is sensitive to Rx.
22Embolization Overall risk : 13 – 44% Decline after effective antimicrobial Rx, thus not necessary to prevent stroke. indicated after a second embolic event after appropriate Rx in patient with persistent vegetations.‘Silent’ emboli, thus screen (CT scan) all patient with large (>1cm) or mobile vegetations prior to
23Emboli ( risk)Cardiopulmonary bypass and need for anticoagulation increases the risk of extending infarct and or converting a nonhemorrhagic infarct into a hemorrhagic lesion.Suggested is postponed 2 weeks after cerebral infarction and 4 weeks after cerebral hemorrhage.May be done before 2 weeks if compelling indications (eg moderate HF).
24Emboli (vegetation size) Larger size larger risk for emboliIn general is not indicated for increase in vegetation size in patient responding well to medical RxVegetations > 10mm by itself is not sufficient to require , unless other complicating features.
25Timing of surgeryConcern: placing prosthetic valve in actively infected tissue !Recommendation: should not be delayed with clear indications regardless of duration of pre-operative antibiotics.
26Antibiotic following surgery 2004 European Society of Cardiology (ESC):Full course of antibiotic Rx if valve culture is positiveIf culture negative, complete full course counting the pre-operative duration of Rx. Minimum duration 7 to 15 days post operative. Rate of relapse 3/358
27ReferenceFauci, AS, Braunwald, E, Harrison’s Principles of Internal Medicine, 17th Edition, 2008Schick, EC, Surgery for native valve endocarditis, Uptodate, June 2008Talley, NJ, O’Conner, S, Clinical examination, 2001