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VALVULAR DISEASE. Mark Boyko, CCFP-EM R3. One night at the Foot…. 64yo male found down at home… -HR 111 -BP 109/67 -RR 12 -Temp 38.6 -O2 88% -Glucose 22. At first glance…. Moving both sides of body (barely) Not speaking to you GCS 9. Labs. -Hgb 108 -WBC 14 -Lytes N

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Valvular disease

VALVULAR DISEASE

Mark Boyko, CCFP-EM R3


One night at the foot
One night at the Foot…

64yo male found down at home…

-HR 111

-BP 109/67

-RR 12

-Temp 38.6

-O2 88%

-Glucose 22


At first glance
At first glance…

  • Moving both sides of body (barely)

  • Not speaking to you

  • GCS 9


Labs

-Hgb 108

-WBC 14

-Lytes N

-EKG pacer spikes



Ddx embolic stroke
DDx Embolic Stroke ? stroke

  • Valvular disease (infective or sterile)

  • Prosthetic valves

  • A fib / Arrythmia

  • MI / Mural thrombus

  • Cardiac tumours

  • Cardiomyopathy (amyloid, sarcoid)

  • Antiphospholipid Ab, pro-thrombotic states

  • R-sided emboli with PFO

  • Carotid plaques


You decide to
You decide to.. stroke

  • Treat for aspiration pneumonia secondary to stroke

  • Intubate for decreased GCS

  • Off to ICU, neuro consult

  • Carotid dopplers N

  • Echo of heart reveals vegetations on mitral valve

  • Blood Cultures later reveal +Strep Bovis


Question
Question stroke

  • Due to his blood culture, what further (non-acute) examination does this patient require in the future?



Question1
Question stroke

Which age group is most commonly affected?

a) < 30 yrs

b) 31-60 yrs

c) >60 yrs


Pathophysiology
Pathophysiology stroke

  • Turbulent flow is the biggest enemy, it denudes the endothelium over time

  • IDU’s  there is often talc mixed in with the drug injection, in addition to cocaine-induced ischemia, causing damage to valves

  • A vegetation begins as platelets and thrombin, and may be sterile at first. But it is a perfect home for a bacteria present in the bloodstream


Transient bacteremia
Transient Bacteremia stroke

  • A brief period where the bacterial count in the bloodstream is <10 organisms/mL blood.

  • This should only last 30min or so, and for most people this is not a problem. However, for people with valvular disease, it is.


Acute vs subacute ie
Acute vs Subacute IE stroke

  • Historically IE classified as acute (rapid onset, hemodynamic compromise) or subacute, but best viewed as a continuum

  • Acute is lethal in days if left untreated

  • For us…

    • Acute: if they are sick and this is a rapid change

    • Subacute: grumbling along last few weeks


Question2
Question stroke

Which microbe causes most cases of IE overall?


Microbiology of ie
Microbiology of IE stroke

  • Overall, #1 cause is Staph Aureus

  • However, many causitive agents, the microbiology of IE is best classified by:

    • Native valve, non-IDU

    • IDU’s

    • Prosthetic Valves


Group 1 native valve non idu
GROUP #1 Native Valve, Non IDU stroke

#1 Streptococcus Viridans (40%)

#2 Staph Aureus (30%)

#3 Enterococci (10%)

#4 HACEK group

*Culture Negative 5% (Coxiella Burnetti, Bartonella)


Question3
Question stroke

Can you name at least 3 organisms in the HACEK group?

…. Alternatively…. Which NHL team first drafted famous Czeck goaltender Dominik Hasek?


Hacek organisms
HACEK Organisms stroke

  • Haemophilus aphrophilus

  • Actinobacillus actinomycetemcomitans

  • Cardiobacterium hominis

  • Eikenella corrodens

  • Kingella kingae


Hacek organisms1
HACEK Organisms stroke

  • Just remember they are GRAM Negative organisms, difficult to culture

  • Collectively, cause 5-10% of IE in people that are not IDU’s


Group 2 injection drug users idu s
GROUP #2 Injection Drug Users (IDU’s) stroke

#1 Staph

#2 Strep

#3 Pseudomonas

#4 Serratia

#5 Fungal (Candida, Apergillis)


Group 3 prosthetic valve
GROUP #3 Prosthetic Valve stroke

#1 Staph Epidermidis (50%)

#2 Streptococcus


Ie risk factors
IE Risk Factors stroke

  • Prior episode IE

  • Prosthetic Valve (same risk mechanical vs biological)

  • Recent invasive procedures

  • Structural Heart Disease (congenital and acquired valvular)

  • IDU


Idu s
IDU’s stroke

  • Right-sided IE

  • Tricuspid > Pulmonary valve

  • PE more common

  • Less likely to have peripheral embolic findings

  • High recurrance rate


Question4
Question stroke

  • Rank the cardiac valves in order of decreasing incidence of IE


Answer
Answer stroke

  • Aortic

  • Mitral

  • Tricuspid

  • Pulmonary


Valves
Valves stroke

  • LEFT-SIDED valves are more commonly hit!

  • However, when all cases of right-sided IE are analyzed, the vast majority occur in IDUs


What about pacemakers
What about Pacemakers? stroke

  • Rare, but can get IE

  • Right-sided vegetations (on either valves or pacer leads)

  • Seen from 0-20 months post insertion

  • Look for hematomas, cellulitis at site

  • Be suspicious!


Question5
Question stroke

  • What percent of people with IE will have a murmur at some point during the course of their illness?


Clinical presentation
Clinical Presentation stroke

  • Fever 80%

  • General malaise 40%

  • Skin manifestations 20-50%

  • Splenomegaly if present for weeks 20%

  • Murmur 30-80% (but almost all will have a murmur at some point during their course of illness)


Better way to remember things
Better way to remember things… stroke

  • Bacteremia-related symptoms

    • Fever, chills, SIRS

  • Cardiac symptoms

    • Chest pain, SOB, CHF

  • Embolic Phenomenon

    • CNS, cardiac, pulmonary, GI, renal, DERM


Question6
Question stroke

Which of the following lesions are painful?

a) Osler’s Nodes

b) Janeway Lesions

c) Splinter hemorrhages

d) Roth spots


Dermatologic findings in ie
Dermatologic Findings in IE stroke

  • These are immune-complexes (bacteria + Ig + fibrin) that have become lodged in distal arterioles, just under the skin.

  • Usually only seen in sub-acute IE because it takes time for them to develop.






EKG stroke

  • Usually normal, but can have new conduction disturbances

    • BBB

    • AV dissociation


Diagnosis of ie
Diagnosis of IE stroke

  • DUKE Criteria

  • Not straight-forward, but sensitivity ~90%

  • We cannot make the diagnosis of IE in the ER! But you must be suspicious.

  • Requires blood cultures to come back, echo to be done, and monitoring over course of an admission.


Blood culture
Blood Culture stroke

  • Key to the diagnosis

  • Draw 3 samples total, 3 different sites

    • 2 different sites at time 0

    • 3rdseparate site at time 1hr

  • 90-95% will be positive if truly IE


ECHO stroke

  • TTE ~60% sensitive for vegetations

  • TEE ~ 80% sensitive for vegetations

  • If TTE negative but clinical suspicion remains high, make sure you get a TEE

  • NPV value for IE with a normal TEE without prosthetic valves ~100%

  • All patients need one within 12hrs, but if they are acutely decompensating order one STAT.


Question7
Question stroke

When is the highest risk for IE after prosthetic valve surgery?

a) 0-6mos

b) 6mos-3yrs

c) 3-10yrs

d) >10yrs


Question8
Question stroke

What is Olser’s Triad?


Osler s triad
Osler’s Triad stroke

  • Pneumonia, endocarditis, meningitis

  • Streptococcus pneumoniae is the culprit

  • Often associated with alcohol abuse, mortality is extremely high


Empiric treatment
Empiric Treatment stroke

Native Valve

  • Ceftriaxone 2g IV, plus

  • Gentamicin 1mg/kg IV q8hrs

    IDU

  • Native valve regimen, plus

  • Vancomycin 15mg/kg IV q12hr

    Prostethic Valve

  • IDU regimen, plus

  • Rifampin 300mg PO TID


Surgical intervention
Surgical Intervention ? stroke

  • Significant valve incompetance (ongoing CHF)

  • Uncontrolled sepsis despite proper Abx

  • Abscess or new conduction disturbance

  • Severe embolic phenomenon

  • Unstable prosthetic

    *Okay to perform surgery in acute setting


Summary ie
SUMMARY - IE stroke

  • Suspect it

  • Exam the hands of your patient

  • Always draw blood cultures x3 before administering antibiotics

  • Order an echo if concerned


Antibiotic prophylaxis
Antibiotic Prophylaxis stroke

Guidelines 2007


Patients at highest risk
Patients at Highest Risk stroke

  • Prosthetic cardiac valve

  • Previous infective endocarditis

  • Congenital heart disease (CHD)

    • Unrepaired or within 6mos of repair

  • Cardiac transplantation with valvular defects


Procedures requiring prophylaxis
Procedures Requiring Prophylaxis stroke

1. ANY dental work

2. Bronchoscopy

3. Skin infection & procedure

*99% of our ER procedures are safe, but use in abscess drainage


Prophylaxis
Prophylaxis stroke

  • Dental/Resp/Esophagael

  • Amoxil 2g PO 30-60min prior

    • *some data that 2hrs post-procedure beneficial is missed initial dose

  • Penicillin Allergy: Clindamycin 600mg PO


Papillary muscle rupture
Papillary Muscle Rupture stroke

  • Very rare (<1% of all MI), but very lethal

  • 80% mortality within 24hrs of rupture without surgical intervention

  • Most often associated with mitral valve regurgitation

  • Timing: From onset of MI to 7 days post-MI

  • Requires urgent cardiac surgery


How? stroke

  • Think about it in your inferior MI’s  disruption of flow in the right coronary artery or circumflex

  • Posteromedial papillary muscle has single blood supply, once cut off, it is vulnerable


Clinical presentation1
Clinical Presentation stroke

  • Tip-offs:

    • New Murmur

    • Respiratory failure / pulmonary edema (esp if no hx CHF)

    • Within hours to 7 days of an inferior MI

  • Seen more commonly in the older patient with his/her first MI


  • Management
    Management stroke

    • Revolves around management of mitral regurgitation

    • Nitrates and Diuretics for CHF

    • IABP as bridging therapy

    • Definitive treatment is surgical repair



    Aortic stenosis1
    Aortic Stenosis stroke

    • Most common valvular lesion among elderly patients

    • “critical” AS is <0.8cm2 or when pressure gradient across valve is >50mmHg

    • Asymptomatic period can last 10-20yrs

    • Once symptomatic, life expectancy only 1-3yrs


    Scarey symptoms
    Scarey Symptoms stroke

    • A ngina

    • S OB

    • S yncope

    • S udden death (not really a symptom!)

      “Classic Triad”:

      CP, CHF, Syncope


    Classic characteristics
    Classic Characteristics stroke

    • Harsh, mid-systolic murmur (later in systole, more severe)

    • Radiation to carotids

    • Decreased pulse amplitude

    • ‘Parvus et Tardus’

    • Narrow Pulse Pressure

    • Brachial-radial delay

    • Louder if patient leans forward


    Remember
    Remember… stroke

    • These patients are PRE-LOAD dependent

    • They have NO CARDIAC RESERVE (essentially, a fixed CO)

    • Medical management is a spit in the ocean, they need surgery


    Acute management
    Acute Management stroke

    • Fluids (even if in CHF, you’ll have to balance diuresis)

    • Blood transfusion

    • Restore NSR

    • AVOID Nitroglycerin, vasodilators. This may kill them

    • Inotropes?  If you’re stuck, you are stuck

    • Call CCU for IABP


    Thanks
    Thanks! stroke


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