Valve Replacement in Infective Endocarditis

PJA SlabbertCardiology

Patient history

34 year male from NCAdmitted KHC : 23/3/10 to 8/4/10 for Infective Endocarditis (culture negative) Pen G and Gentamycin

Clinically deteriorated over 3 days and follow up echocardiogram showed: Worsening heart failure More extensive vegetations on aorta

valves

Systemic enquiry: Neurology: no TIA, no amurosis fugax Respiratory: 3 weeks non productive cough,

progressive dyspnoea Cardiology: 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

ExaminationGeneral: 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% oxygen

Diffuse fungal/ yeast skin infection: Pityriasis versicolor

No peripheral manifestations of infective endocarditis: Roth spots, subungual hemorrhages, Janeway lesions

Cardiovascular Water hammer pulse, equal pulses and

BP left and right. Elevated JVP 2cm above baseline

Apex displaced inferior lateral: 6th ics aal

Loud P2, C3 both ventricles Decrescendo diastolic murmur

parasternally with ejection systolic murmur not radiating. No Austin Flint

Respiratory: Diffuse inspiratory crackles Distressed : tachypnoea, accessory

muscle use.

Abdomen: No Hepatomegaly, No splenomegaly

Urine Dipstix : no microscopic hematuria

Problem List

Infective EndocarditisSevere Aorta Regurgitation with signs of bi-ventricular failurePulmonary edema with acute respiratory failure

Special investigationBloods: FBC : WCC 8.4, Hb 14.1, plt 191 U&E : Na 136, K 5.2, Urea 17.6, Cr 133 LFT : t-prot 72, alb 25, t-Billi 35, c-Billi 16, ALP

109, GGT 108, AST 165, ALT 293, LDH 150 CRP 5.2 Trop-T : negative, CK : normal ASOT negative, ANA negative, RF negative,

RPR negative, HIV negative BC negative

Cardiac echo CXR ECG

ECG

CXR

echoAorta root diameter = 30 mm (normal)Aorta valve opening = 21 mm (normal)Vegetation on all three aorta cuspsPressure half time = 67 ms (<200ms severe acute AR)Mitral valve : mild regurgitationLeft Atrium : 4.3 cm (enlarged)Left ventricle: LVEDD 6.5 cm, LVESD 5 cm, LVEF = 44%Right heart mildly enlarged, mild TI, RVPSP = 65 mmHg

Treatment

Furosemide 40 mg bd iviEnalapril 5 mg bd poElantin 20 mg bd poPen G, Gentamycin, Cloxacillin, DiflucanUrgent cardio-thoracic consult Ross procedure was done

Surgery in NVE

Introduction 1961 : Kay and colleagues excised fungal

vegetation from tricuspid valve 1965 : AVR in IE due to Serratia Marcescens Last 3 decades : valve replacement/ repair

common in Mx of complicated IE Decreased mortality in IE due to

combination of antibiotics and timely surgical intervention

Indications

2006 American College of Cardiology/ American Heart Association (ACC/ AHA) Surgery is warranted for native valve IE who

have one or more of the following 1. 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

Other 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

Choice of procedure

For active infection (2006 ACC/AHA): Valve repair rather than replacement

Only possible in minority of cases Thus leaflet perforation without

destruction or annular involvement.

Heart 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)

Caveats Non cardiac factors that exaggerate HF

Fever, anemia, sepsis, renal insufficiency Hx of previous HF.

HF out of proportion to valve dysfunction.

Complicated infection

Persistent positive BC 5 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 perforation Serial TEE and early in presence of known

difficult organism.

New heart block

Fungal 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.

Embolization

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

Emboli ( 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).

Emboli (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.

Timing of surgery

Concern: placing prosthetic valve in actively infected tissue !Recommendation: should not be delayed with clear indications regardless of duration of pre-operative antibiotics.

Antibiotic following surgery

2004 European Society of Cardiology (ESC): Full course of antibiotic Rx if valve

culture is positive If 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

Reference

Fauci, 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

Q & A

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