Download CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS

“CHALLENGING ISSUES IN INFECTIVE
ENDOCARDITIS”
ISKANDER AL-GITHMI, MD, FRCSC
Consultant Cardiothoracic Surgeon
Assistant Professor of Surgery
King Abdulaziz University
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
“Endocarditis Milestones”
 1885 - Clinical syndrome; described by Sir William
Osler.
It is of use, from time to time, to take stock, so to speak of
our knowledge of a particular disease, to see exactly
where we stand in regards to it, to inquire to what
conclusion the accumulated facts seem to point and to
ascertain in what direction we may look for fruitful
investigation in the future….I propose to do this in the
case of that most interesting disease known as ulcerative
endocarditis.
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
 1944 - Penicillin (Alexander Fleming)
 1981 - Von Reyn Criteria [Persistant bacteremia, New
regurgitant murmur and vascular Complications]
 1994 - Duke’s Criteria proposed by Dr. Durack from
Duke University.
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
“Background”
 Despite improvement in health care and advancement in
diagnostic technology and therapy; the incidence of
infective endocarditis has not decreased over the past
decades.
 Progressive evolution in risk factors:
- i.e. i.v. drug use
- Use of prosthetic valve
- Growing resistant micro-organisms.
 Incidence of Infective endocarditis ~ 15000 to 20,000 new
cases per year.
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
Infective endocarditis classifications:
 Native – valve endocarditis: associated with congenital
heart disease and chronic rheumatic heart disease.
 Prosthetic-valve endocarditis:
1-5% of individual with infective endocarditis have PVE
Early-PVE: infection within 60 days of surgery
Late -PVE: infection 2-6 months of surgery
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
 Infective endocarditis in intravenous drug user
- Common in young population
- Tricuspid valve involved in up to 50% of cases
- Predominant pathogenes usually staph aureus
 Important iatrogenic risk
endocarditis - hemodialysis
factors
for
infective
- 3 times more frequent than in general population
- Predominant pathogenes is staph aureus.
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
“Pathogenesis”
 Bacterial adherence to damaged valve:
- Mechanical lesions
- Inflammatory lesions
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
“Diagnosis Pre-requisite”
 High index of suspicious
 Early TEE: High sensitivity 75-95%
Specificity 85-98%
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
Duke Clinical Criteria
Definite IE
Pathological criteria
Microorganisms:
demonstrated by culture or histology in a vegetation,
in a vegetation that has embolized, or in an intracardiac
abscess, or
Patological lesions: vegetation or intracardiac abscess present, confirmed
by histology showing active endocarditis
Clinical Criteria, using specific definitions listed in Table
major criteria or
major and minor criteria, or
minor criteria
Possible IE
Findings consistent with Ied that fall short of "Definite" but not "Rejected"
Rejected
Firm alternate diagnosis for manifestation of endocarditis, or
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
“Management Strategies”
 It is multi-disciplinary and team work
- Cardiologist
- Echo Cardiologist
- Cardiac Surgeon
- Infectious Disease
- Neurologist
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
“Echocardiography in infective endocarditis”
 Extremely important not only to make diagnosis but for
early detection of potential complications.
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
 Major Complications
- Thrombo-embolism
- Heart Failure
- Peri-annular extension of infection and
annular dehiscence
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
 Thrombo-embolism
Major 30 – 40%
Rate 50%
Sub-clinical 10-20%
 Up to 65% of embolic event involve CNS
 90% of CNS embolism lodge in the distribution of middle
cerebral artery.
 More than 90% of embolization developed within the 1st 3
weeks of the diagnosis of infective endocarditis
 The rate of embolization decreased overtime during antimicrobial therapy.
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
Results of Previous Studies
Relation Between EEs Patients Embolic Events
and Vegetation Size
(n)
(%)
Author (ref.)
Lutas et. al. ( )
Mugge et. al. (
Jaffe et. al. (
)
Echocardiography
Negative
TTE
Positive
TTE
Negative
TTE
)
Positive
TTE
Steckelberg et. al. ( )
Negative
Rohmann et. Al. (
Positive
TEE biplane
Negative
TTE
Heinle et. al. (
Werner et. al. (
Present study
)
)
Positive, >
)
De Castro et. al. (
Embolic Events
During Therapy
ND
TEE biplane
)
Sanfilippo et. Al. (
Detected Vegetations
(%)
*
mm
TTE
TEE biplane
TEE monoplane (
)
Negative
+
TTE
TEE multiplane
Positive
ND
TEE multiplane
ND
%)
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
 Echocardiography predicts
infective endocarditis.
embolic
events
in
 Study design: Prospective
 Patients: 178 Consecutive patients with definite
diagnosis of infective endocarditis
All had multi-plane TEE
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
Results of Univariate and Multiple Stepwise Logistic Regression
Multivariate Analysis
Univariate
p Value
Presence of vegetation
Vegetation length
.
p Value
B
Exp B
NS
.
.
. - .
.
.
.
. - .
< .
Vegetation mobility
.
.
Mitral valve vegetation
NS
NS
Aortic valve vegetation
NS
NS
Right valve vegetation
.
NS
Multiple valve vegetation
NS
NS
Staphylococcal IE
.
NS
CI = confidence interval; IE = infective endocarditis; NS = not significant
% CI
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
“Clinical Implications of the Study”
 The presence of vegetation visualized
echocardiogram is a predictive of embolism
by
 The morphological characteristic of vegetations are
very helpful in predicting the embolic events.
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
“What is the time interval required for
surgical intervention in infective
endocarditis?”
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
 Presence of vegetations is a strong indication for
surgical intervention, irrespective of valve
destruction, heart failure or response to antimicrobial therapy.
 Embolic events is extremely high in the early
stage of the disease.
 Embolic events can occur up to 20% of cases
from vegetation less than 10mm.
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
“Congestive Heart Failure (CHF)”
 CHF may develop insidiously, despite appropriate
antibiotics as a result of progressive valvular insufficiency
and ventricular dysfunction.
 CHF in infective endocarditis; portends a grave prognosis
with medical therapy.
 Delaying surgery to the point of ventricular
decompensation dramatically increase operative mortality
from 6% to 11% for patient without CHF, 17-33% for
patient with CHF.
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
 Periannular extension of infection and annular dehiscence
- Extension of infective endocarditis beyond
the valve annulus predict higher mortality,
more frequent development of CHF and the
need for surgical intervention.
- It occurs in 10-40% of all native-valve
endocarditis and 56% to 100% in PVE.
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
“Management Approach to Infective
Endocarditis”
 Surgical versus medical therapy in
active complicated native valve
infective endocarditis.
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
Indications for Surgery (Group A) and Criteria for Inclusion in Group B
Group A
( patients)
n
%
Group B
( Patients)
n
%
p Value
CHF (Class III and IV, NYHA)
NS
Persistent Infection
NS
Persistent Systemic Hypotension
NS
Root Abscess
NS
Pericarditis
NS
CHF = congestive heart failure; NYHA = New York Heart Association; NS - not significant
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
Site of Involvement by Endocarditis
Group A
( patients)
n
%
Mitral
Group B
( Patients)
n
%
p Value
NS
Aortic
< .
Mitral + Aortic
NS
Mitral + Aortic + Tricuspid
...
...
Mitral + Tricuspid
...
...
Aortic + Tricuspid
...
...
NS=not significant; PDA=patent ductus arteriosus; VSD=ventricular septal defect
*For group comparison, p= .
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
“Conclusions”
 Despite improvement in healthcare and major advance in
the diagnostic technology as well as medical-surgical
therapies, endocarditis has not decreased but new risk
factors have evolved.
 Treatment of this infection require a multidisciplinary
approach.
 Early surgery is critically important and maybe the only
best option in patients with infective endocarditis
irrespective of heart failure, valve destruction and
response to antimicrobial therapy.
 New clinical research studies should be used to provide
definite answers to several remaining questions about this
complex infection.