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INFECTIVE ENDOCARDITIS. Manoj Kuduvalli. Definition. Bacterial or Fungal infection within the heart (although chlamydial and rickettsial infections are known) ; the role of viruses is unknown. ORIGINAL CLASSIFICATION (Prior to Antibiotic era). Current Criteria for Classification.

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Infective endocarditis l.jpg

INFECTIVE ENDOCARDITIS

Manoj Kuduvalli


Definition l.jpg

Definition

Bacterial or Fungal infection within the heart (although chlamydial and rickettsial infections are known) ; the role of viruses is unknown


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ORIGINAL CLASSIFICATION(Prior to Antibiotic era)


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Current Criteria for Classification

Underlying Anatomy:

› Native Valve Endocarditis

› Prosthetic Valve Endocarditis

Infecting Organism

› Serves as basis for therapy and prognosis


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Native Valve EndocarditisUnderlying Predisposing Conditions

›› 60 - 80% of non IV Drug abusers have a

predisposing condition

› Mitral Valve Prolapse 30 - 50%

› Rheumatic Heart Disease 20 - 40%

› Degenerative Aortic and 20 - 30%

Mitral valve disease

› Congenital Heart Disease 10 - 20%


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Native Valve EndocarditisMicrobiology

›› Streptococci 50 - 70%

Viridans Streptococci (50% of all Strep)

›› Staphylococci ~ 25%

Mostly Coagulase +ve Staph. Aureus

Staph. Epidermidis

›› Enterococci ~ 10%


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Viridans Streptococci

Infect primarily abnormal valves

Indolent clinical course

Highly sensitive to Penicillins

Staph. aureus

Infect normal and abnormal valves

Fulminant course with rapid destruction of valves and multiple metastatic abscesses

Mostly resistant to Penicillins and sensitive to penicillinase resistant ß-lactams

Common with soft tissue infections, and infected IV catheters

Native Valve EndocarditisMicrobiology


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Staph. Epidermidis

Indolent Course

Affects abnormal valves

Enterococci

Normally affects damaged valves

Recent history of genitourinary or gastrointestinal manipulation, disease or trauma

Usually sensitive to Penicllin+Gentamicin

Resistant strains prevalent

Native Valve EndocarditisMicrobiology


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Prosthetic valve endocarditis

  • 5 - 15% of all Infective Endocarditis

  • Overall incidence 1 - 4%

  • Risk of PVE peaks at 15 days postop. , then rapidly declines by 150 days


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Early ( < 60 days )

Reflects perioperative contamination

Incidence around 1%

Microbiology

Staph (45 - 50%)

Staph. Epiderm (~ 30%)

Staph. Aureus (~ 20%)

Gram -ve aerobes (~20%)

Fungi (~ 10%)

Strep and Entero (5-10%)

Late ( > 60 days)

After endothelialization

Incidence 0.2 -0.5 % / pt. year

Transient bacteraemia from dental, GI or GU

Microbiology

resembles native valve endocarditis

Prosthetic Valve EndocarditisClassification


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IE in IV Drug Abusers

Right sided predilection

Tricuspid Valve ~ 55%

Aortic Valve ~ 25%

Mitral Valve ~ 20%

Pulmonary Valve 1 - 1.5%

Mixed Rt. And Lt. Side 5 - 6%


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IE in IV Drug Abusers

  • Skin most predominant source of infection

  • Also contamination of drugs and paraphernalia

  • 70 - 100% of Rt. sided IE results in pneumonia and septic emboli

  • Microbiology

    • Staph aureus ~60%

    • Streptococci and Enterococci ~20%

    • Gram -ve bacilli ~10%

    • Fungi (Candida and Aspergillus ~5%


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IE in adults with congenital heart disease

Common defects

VSD PDA

Bicuspid AV PS

Coarctation of Aorta

Occurs in defects with

--mild or no hemodynamic consequences

--high gradients

--high velocity jets impinging on endocardium


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Microbiology very important since virulence of the infecting organism is a significant factor in determining the success rates of both medical and surgical treatment


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Pathogenesis organism is a significant factor in determining the success rates of both medical and surgical treatment

Requires interaction between

› Host vascular endothelium

› Host haemostatic response

› Adventitiously circulating organisms


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Pathogenesis of Vegetations organism is a significant factor in determining the success rates of both medical and surgical treatment


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Hemodynamic factors predisposing to Infective Endocarditis organism is a significant factor in determining the success rates of both medical and surgical treatment

  • High velocity abnormal jet stream

  • Flow from high to low pressure chamber

  • Narrow orifice between two chambers creating pressure gradient


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Pathology organism is a significant factor in determining the success rates of both medical and surgical treatment


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Common sites of origin of extravalvular spread organism is a significant factor in determining the success rates of both medical and surgical treatment


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Pathology organism is a significant factor in determining the success rates of both medical and surgical treatment

Initially affects

Valve leaflets in native valve endocarditis

Can extend into annulus

Annulus in prosthetic valve endocarditis

Due to presence of sewing rim


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Pathology - organism is a significant factor in determining the success rates of both medical and surgical treatmentEmbolic Phenomena

  • Incidence

    • Clinically 15 - 45%

    • Pathologically 45 - 65%

  • More with large mobile vegetations

    • Fungi (Candida and Aspergillus)

    • Group B and G Streptococci

    • Staph aureus

  • Result in

    • Infarcts

    • Abscesses

    • Mycotic aneurysms


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Pathology organism is a significant factor in determining the success rates of both medical and surgical treatmentImmune Complex Associated

  • Glomerulonephritis

  • Arthritis

  • Osler’s nodes


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Clinical Features organism is a significant factor in determining the success rates of both medical and surgical treatment

Onset usually within 2 weeks of infection

› Indolent course

- Malaise

- Fatigue

- Night sweats

- Anorexia

- Weight loss

› Explosive course

- CCF

- S/o severe systemic sepsis


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Clinical features organism is a significant factor in determining the success rates of both medical and surgical treatment

› Fever

- Usually < 39 °C, remittent

- May be absent in

- elderly

- severe debility

- CCF

- Already on antibiotics

› Murmurs

- Appearance of new murmur or true

change in existent murmur indicates

infection with virulent organism


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Other Clinical Features organism is a significant factor in determining the success rates of both medical and surgical treatment

  • Splenomegaly ~ 30%

  • Petechiae 20 - 40%

    • Conjunctivae

    • Buccal mucosa

    • palate

    • skin in supraclavicular regions

  • Osler’s Nodes 10 - 25%

  • Splinter Haemorrhages 5 - 10%

  • Roth Spots ~ 5%

  • Musculoskeletal (arthritis)


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Complications organism is a significant factor in determining the success rates of both medical and surgical treatment

  • Congestive Cardiac Failure (Commonest complication)

    • Valve Destruction

    • Myocarditis

    • Coronary artery embolism and MI

    • Myocardial Abscesses

  • Neurological Manifestations (1/3 cases)

    • Major embolism to MCA territory ~25%

    • Mycotic Aneurysms 2 - 10%


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    Complications organism is a significant factor in determining the success rates of both medical and surgical treatment

    • Metastatic infections

      • Rt. Sided vegetations

        • Lung abscesses

        • Pyothorax / Pyopneumothorax

      • Lt. Sided vegetations

        • Pyogenic Meningitis

        • Splenic Abscesses

        • Pyelonephritis

        • Osteomyelitis

    • Renal impairment d/t Glomerulonephritis


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    Diagnosis organism is a significant factor in determining the success rates of both medical and surgical treatment

    • Blood Cultures

      • Positive in 95% cases

    • Other Laboratory Parameters

      • Anaemia

      • Leucocytosis (WCC may be normal in indolent infection)

      • Thrombocytopenia

      •  ESR (may be absent in CCF and renal failure)

      • Urine - Microscopic hematuria / proteinuria


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    Echocardiography organism is a significant factor in determining the success rates of both medical and surgical treatment

    • Can demonstrate lesion / vegetation in 60 - 80% of cases

    • Difficult in prosthetic valve endocarditis

    • TOE better than TTE

    • Can demonstrate

      • Morphology of valve

      • Annular abscesses

      • Hemodynamics of the valves

    • Serial observations can contribute to decision for surgery


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    Treatment organism is a significant factor in determining the success rates of both medical and surgical treatment

    Medical

    Surgical


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    Principles of Medical Management organism is a significant factor in determining the success rates of both medical and surgical treatment

    Sterilization of Vegetations with antibiotics

    - prolonged Slowly metabolising bacteria

    due to high density, hence  sensitivity

    - high dose

    Bacteria deep inside

    vegetations

    -bactericidal


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    Principles of Medical Management organism is a significant factor in determining the success rates of both medical and surgical treatment

    Acute onset, fulminant

    -Within two to three hours of

    clinical diagnosis.

    -Take cultures, but do not wait

    for results

    Timing of Therapy

    Subacute onset, or having

    received recent antibiotic

    -Within two to three days. -Can wait for culture reports


    Principles of medical management34 l.jpg
    Principles of Medical Management organism is a significant factor in determining the success rates of both medical and surgical treatment

    • Isolation of organisms very important

    • Therapy before isolation of organism

      • Native valve endocarditis and in IV drug abusers

        • Directed against Staph aureus

      • Prosthetic valve endocarditis

        • Broad spectrum antibiotics directed against

          • Staph aureus

          • Staph epidermidis

          • Gram –ve bacilli


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    Indications for Surgery organism is a significant factor in determining the success rates of both medical and surgical treatmentLeft sided native valve endocarditis

    • Valvular disruption leading to severe insufficiency and CCF

    • Extravalvar extension

    • Embolization of vegetations

    • Failure of medical management

      Positive blood culture and systemic signs of infection after “adequate” antibiotic therapy

    • Resistant organisms

      such as MRSA, Fungi , Pseudomonas

    • Echo detected vegetation > 1 cm ??


    Indications for surgery right sided native valve endocarditis l.jpg
    Indications for Surgery organism is a significant factor in determining the success rates of both medical and surgical treatmentRight sided native valve endocarditis

    Indications differ because:

    - Consequences of valve disruption and emboli are less

    - Success with antibiotics seems to be better

    --Failure of medical treatment

    --CCF, with its complications Indications (elective)

    --Recurrent pulmonary emboli

    with complications

    --Extravalvar spread (rare)


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    Indications for surgery organism is a significant factor in determining the success rates of both medical and surgical treatmentProsthetic valve endocarditis

    • Early infection almost always require surgery

    • Late infection

      Antibiotic therapy succeeds more often with

      Bioprosthesis compared to mechanical valves

      CCF due to prosthesis dysfunction

      Indications Multiple emboli

      Persistent infection


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    Indications for Surgery organism is a significant factor in determining the success rates of both medical and surgical treatmentSpecial situations

    AIDS

    Not usually indicated since life expectancy due to AIDS very poor

    HIV +ve patient without AIDS

    IV Drug Abusers

    No change in indications since enough number survive > 10 years


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    When to operate ? organism is a significant factor in determining the success rates of both medical and surgical treatment

    As soon as there is a major indication

    Valid reasons for delay

    Acute CNS injury

    --Hemorrhagic infarct (Wait for 10 days to allow healing)

    --Coma (very poor prognosis )

    Renal failure due to Glom’nephritis

    Follow through the acute phase

    (Prerenal failure -- early operation)


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    Principles of operation organism is a significant factor in determining the success rates of both medical and surgical treatment

    Repair or Replacement ?

    (More important with mitral valves)

    Repair contemplated only if:

    --Infection well controlled

    --Repair structurally feasible after involved tissue excised


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    Principles of operation organism is a significant factor in determining the success rates of both medical and surgical treatment

    • Early operation once indicated

    • Preop. knowledgeof morphology of valve

    • Good exposure(may be difficult in mitrals)

    • Excision and debridement of all infected or involved tissue even if extensive reconstruction or permanent pacing required


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    Principles of operation organism is a significant factor in determining the success rates of both medical and surgical treatment

    • Lookfor extravalvar extension

    • If present,evacuate abscess cavity and repairwith biological material such as autologous or bovine pericardium

    • Suturevalve onto clean and relatively strong tissue

    • Temporary pacing leads


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    Stented Bioprosthesis organism is a significant factor in determining the success rates of both medical and surgical treatment

    Mechanical

    Which Prosthesis?

    Stentless Bioprosthesis

    Homograft


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    Choice of prosthesis organism is a significant factor in determining the success rates of both medical and surgical treatment

    Important factor is location of infection

    -- Infection of cusps only:

    Choice does not matter, since all infected tissue is usually excised

    -- Perivalvar extension:

    No choice between mechanical and stented bioprosthesis (both with cloth sewing rims)

    Homograft, maybe stentless bioprosthesis have lesser incidence of infection


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    Choice of prosthesis organism is a significant factor in determining the success rates of both medical and surgical treatmentMechanical v/s Bioprosthetic

    • No difference in linearized rates for recurrent or residual infection (~1-2% per patient year)

    • No difference in operative mortality and complication free survival

    • Infected bioprosthesis more easily sterilized (since infection initially involves leaflets)

    • However, infection in bioprosthesis may hasten SVD due to damage to leaflets


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    Choice of prosthesis organism is a significant factor in determining the success rates of both medical and surgical treatmentHomograft v/s others

    • Hazard function for recurrent endocarditis has only low constant phase and has no high early hazard phase like other prosthesis

    • Homograft best choice if valved conduit is required for root replacement ( > 50% annular dehiscence or aortoventricular discontinuity)


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    Postoperative Antibiotics organism is a significant factor in determining the success rates of both medical and surgical treatment

    To continue for 6 weeks if

    › Operated for --Acute fulminant infection

    --Failure of medical therapy

    --Resistant organisms

    › Excised valve yields positive cultures

    › Periannular involvement

    › Valve culture –ve, but organisms seen on

    histology

    › Positive blood cultures 3 – 4 days postop.


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    Results of Treatment organism is a significant factor in determining the success rates of both medical and surgical treatmentNative valve endocarditisMedical Management

    Mortality 10 – 60 %

    Risk Factors

    Virulent organisms s/a MRSA, G-ve bacilli, fungi

    CCF

    Persistence of systemic sepsis

    Major septic embolus

    Extravalvar extension

    Acute renal failure


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    Results of Treatment organism is a significant factor in determining the success rates of both medical and surgical treatmentNative valve endocarditisSurgical Management

    Hospital Mortality 5 – 20%

    Risk factors

    Virulent organisms

    Perivalvar extension

    Intractable CCF

    Renal and multiorgan failure


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    Results of Treatment organism is a significant factor in determining the success rates of both medical and surgical treatmentNative valve endocarditisSurgical Management

    Recurrent Endocarditis ~ 2%

    Most occurs within 2 months post op.

    Same organism

    No fresh source of infection

    Perivalvar leaks 3-7%


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    Results of Treatment organism is a significant factor in determining the success rates of both medical and surgical treatmentProsthetic valve endocarditisMedical Management

    Mortality ~ 70%

    Risk factors

    Valve incompetence or perivalvar leak

    Early postoperative onset

    Virulent organism


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    Results of Treatment organism is a significant factor in determining the success rates of both medical and surgical treatmentProsthetic valve endocarditisSurgical Management

    Hospital Mortality 0 –22%

    Risk factors

    Early postoperative infection

    Virulent organism

    Perivalvar extension

    Delay in operation


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    Results of Treatment organism is a significant factor in determining the success rates of both medical and surgical treatmentProsthetic valve endocarditisSurgical Management

    • Long term results differ from valve replacement for NVE or other lesions

    • Have comparatively unfavourable rates of late death, recurrence of infection and reoperation


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    Antibiotic Prophylaxis organism is a significant factor in determining the success rates of both medical and surgical treatment

    Protocol usually followed recommended by Dajani et al in JAMA 1990

    Recommended in following conditions

    Prosthetic valves

    Previous history of infective endocarditis (even without underlying heart disease)

    Most congenital heart diseases

    Rheumatic or other acquired valve disease

    IHSS

    MVP with MR


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    Thank you! organism is a significant factor in determining the success rates of both medical and surgical treatment