INFECTIVE ENDOCARDITIS NISHITH PATEL WAIKATO CARDIOTHORACIC UNIT TEACHING

INFECTIVE ENDOCARDITIS NISHITH PATEL WAIKATO CARDIOTHORACIC UNIT TEACHING

GUIDELINES • EUROPEAN SOCIETY OF CARDIOLOGY 2015 GUIDELINES FOR THE MANAGEMENT OF IE • AHA GUIDELINES 2015 FOR THE MANAGEMENT OF IE IN ADULTS • AATS 2016 GUIDELINES FOR THE SURGICAL TREATMENT OF IE • NICE GUIDELINE 2017 FOR THE PROPHYLAXIS AGAINST IE

DIAGNOSIS OF IE

MODIFIED DUKE CRITERIA Sensitivity – 80%. Lower diagnostic accuracy in PVE and pacemaker or defib lead IE (ECHO is normal or inconclusive in 30%)

PRESENTATION - CLINICAL FEATURES • FEVER – 90% OF PATIENTS • +/- SYSTEMIC FEATURES – WT LOSS, ANOREXIA • HEART MURMUR – 85% OF PATIENTS • EMBOLIC COMPLICATIONS – 25% OF PATIENTS • EMBOLI TO BRAIN, LUNG OR SPLEEN – 30% OF PATIENTS • SUSPECT IE IN PATIENTS WITH FEVER AND EMBOLIC PHENOMENA

IMAGING • ECHO – TTE AND TOE • PET-CT – POSSIBLE IE DIAGNOSIS, DETECTION OF PERIPHERAL EMBOLI • CT – CORONARIES, ABSCESSES, PSEUDOANEURYSMS, BRAIN LESIONS • MRI – CEREBRAL LESIONS (GREATER SENSITIVITY THAN CT)

ECHO

ECHO – TTE VS TOE Sensitivity/Specificity TTE TOE NVE 70% / 90% 96% / 90% PVE 50% 92% 50% / 90% VEGETATIONS ABSCESS Suspect PVE in patients with new paravalvular regurgitation

IN SUMMARY, ECHOCARDIOGRAPHY (TTE AND TOE), POSITIVE BLOOD CULTURES AND CLINICAL FEATURES REMAIN THE CORNERSTONE OFIE DIAGNOSIS. WHEN BLOOD CULTURES ARE NEGATIVE, FURTHER MICROBIOLOGICAL STUDIES ARE NEEDED. THE SENSITIVITY OF THE DUKE CRITERIA CAN BE IMPROVED BY NEW IMAGING MODALITIES (MRI, CT, PET/CT) THAT ALLOW THE DIAGNOSIS OF EMBOLIC EVENTS AND CARDIAC INVOLVEMENT WHEN TTE/TOE FINDINGS ARE NEGATIVE OR DOUBTFUL. THESE CRITERIA ARE USEFUL, BUT THEY DO NOT REPLACE THE CLINICAL JUDGEMENT OF THE ENDOCARDITIS TEAM.

PROGNOSIS

PROGNOSTIC INDICATORS • IN-HOSPITAL MORTALITY RATE: 1530% • 4 MAIN FACTORS: • PATIENT CHARACTERISTICS • PRESENCE OR ABSENCE OF CARDIAC AND NON-CARDIAC COMPLICATIONS • INFECTING ORGANISM • ECHO FINDINGS

ANTIMICROBIAL THERAPY

PRINCIPLES • ANTIMICROBIALS ERADICATE MICROBIAL BURDEN • SURGERY REMOVES INFECTED MATERIAL AND DRAINS ABSCESSES • NVE – 2 -6 WEEK THERAPY • PVE - >6 WEEKS THERAPY • BIOFILMS - HOUSE SLOW-GROWING AND DORMANT MICROBES • DURATION OF THERAPY IS BASED ON THE FIRST DAY OF EFFECTIVE ABX THERAPY • NEGATIVE BLOOD CULTURE IN THE CASE OF INITIAL POSITIVE BLOOD CULTURE • NOT ON THE DAY OF SURGERY • NEW FULL COURSE TREATMENT STARTS IF VALVE CULTURES ARE POSITIVIE

BLOOD CULTURE NEGATIVE IE

EMPIRICAL ANTIMICROBIAL THERPAY

SURGERY

SURGERY FOR IE • 50% OF PATIENTS WITH IE REQUIRE SURGERY • INDICATIONS FOR SURGERY • TIMING OF SURGERY • HEART FAILURE MOST COMMON COMPLICATION OFIE (40 -60% OFNVE) • NEW VALVE REGURGITATION (CHORDAL RUPTURE, LEAFLET RUPTURE, PERFORATION, INTERFERENCE BY THE VEGETATION) • FISTULAE

PREOP ASSESSMENT • OPERATIVE RISK ASSESSMENT • STS IE SCORE – BETTER PREDICTIVE VALUE VS EUROSCORE II • CORONARY ANGIOGRAPHY • INDICATIONS: MEN >40 Y, POST-MENOPAUSAL WOMEN, 1 OR MORE CV RISK FACTOR OR HX OF CAD • EXCEPTIONS: AORTIC VEGETATIONS, EMERGENCY SURGERY • CT CORONARY ANGIO • EXTRACARDIAC INFECTION • ERADICATE ANY PRIMARY EXTRACARDIAC FOCUS OF INFECTION PRIOR TO SURGERY UNLESS SURGERY IS URGENT • ? BRAIN IMAGING

SURGICAL APPROACH AND TECHNIQUES • OBJECTIVES: • COMPLETE REMOVAL OF INFECTED TISSUES • RECONSTRUCTION OF CARDIAC MORPHOLOGY • BIOPROSTHESIS VS MECHANICAL VALVES • REPAIR PREFERRED IN MV IE • ROOT ABSCES • HOMOGRAFTS • STENTLESS XENOGRAFTS

POSTOPERATIVE COMPLICATIONS • MORTALITY – 10 -20% IN ACUTE CASES • COAGULOPATHY • RE-EXPLORATION FOR BLEEDING AND TAMPONADE • AKI – F • STROKE • LOW CARDIAC OUTPUT • PNEUMONIA • AV BLOCK – PREOP LBBB ON ECG

FOLLOW-UP • RISK OF RECURRENCE – 2 -6% • LONG-TERM SURVIVAL IN ALL TREATED PATIENTS: • 80 -90% AT 1 YEAR • 60 -70% AT 5 YEARS

SPECIFIC SCENARIOS

PROSTHETIC VALVE ENDOCARDITIS • PVE OCCURS IN 1 -6% OF PATIENTS WITH VALVE PROSTHESES • PVE ACCOUNTS FOR 10 -30% OF IE • MECHANICAL = BIOPROSTHESES • PVE – NEW VALVE REGURGITATION • DIAGNOSTIC CHALLENGE • ECHO OFTEN NEGATIVE • PERSISTENT FEVER AND NEW PARAVALVULAR LEAK • ADDITIONAL IMAGING – CT, PET • HIGHER MORTALITY RATE – 20 -40% • SURGERY INDICATED IN MOST CASES

RIGHT SIDED IE • 5 -10% OF IE CASES • S. AUREUS ACCOUNTS FOR 60 -90% OF CASES • COMMONLY IN IVDU • IN-HOSPITAL MORTALITY – 7%

PREVENTION

PREVENTION OF IE • A MOVE AWAY FROM ANTIBIOTIC PROPHYLAXIS FOR THE PREVENTION OF IE: • LOW GRADE BUT REPEATED BACTERAEMIA MORE RELEVANT FOR THE DEVELOPMENT OF IE THAN SPORADIC HIGH-GRADE BACTERAEMIA SEEN WITH DENTAL PROCEDURES • STUDIES DO NOT DEMONSTRATE AN ASSOCIATION BETWEEN INVASIVE DENTAL PROCEDURES AND OCCURRENCE OF IE • ESTIMATED RISK OF IE FOLLOWING DENTAL PROCEDURES WITHOUT ABX: 1 PER 46 000 • 2008 ONWARDS – RESTRICTION OF ABX PROPHYLAXIS FOR DENTAL PROCEDURE TO THE HIGEST RISK PATIENTS.

STUDIES • DAYER MJ, JONES S, PRENDERGAST B, BADDOUR LM, LOCKHART PB, THORNHILL MH. INCIDENCE OF INFECTIVE ENDOCARDITIS IN ENGLAND, 2000– 13: A SECULAR TREND, INTERRUPTED TIME-SERIES ANALYSIS. LANCET 2015; 385: 1219– 1228. • DUVAL X, DELAHAYE F, ALLA F, TATTEVIN P, OBADIA JF, LE MV, DOCO-LECOMPTE T, CELARD M, POYART C, STRADY C, CHIROUZE C, BES M, CAMBAU E, IUNG B, SELTONSUTY C, HOEN B. TEMPORAL TRENDS IN INFECTIVE ENDOCARDITIS IN THE CONTEXTOF PROPHYLAXIS GUIDELINE MODIFICATIONS: THREE SUCCESSIVE POPULATION-BASED SURVEYS. J AM COLL CARDIOL 2012; 59: 1968– 1976. • DESIMONE DC, TLEYJEH IM, CORREA DE SA DD, ANAVEKAR NS, LAHR BD, SOHAIL MR, STECKELBERG JM, WILSON WR, BADDOUR LM. INCIDENCE OF INFECTIVE ENDOCARDITIS CAUSED BY VIRIDANS GROUP STREPTOCOCCI BEFORE AND AFTER PUBLICATION OF THE 2007 AMERICAN HEART ASSOCIATION’S ENDOCARDITIS PREVENTION GUIDELINES. CIRCULATION 2012; 126: 60– 64.

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