Valve Replacement in Infective Endocarditis PJA Slabbert Cardiology

Patient history 34 year male from NC Admitted KHC : 23/3/10 to 8/4/10 for Infective Endocarditis (culture negative) n Pen G and Gentamycin Clinically deteriorated over 3 days and follow up echocardiogram showed: n n Worsening heart failure More extensive vegetations on aorta valves

Systemic enquiry: n n 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: n D-E-A-T-H-, not known with cardiac condition, no chronic medication

Examination General: n n Chronically ill: underweight J-A-C-C-O+LBP 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: w Pityriasis versicolor n No peripheral manifestations of infective endocarditis: Roth spots, subungual hemorrhages, Janeway lesions

Cardiovascular n n Water hammer pulse, equal pulses and BP left and right. Elevated JVP 2 cm above baseline Apex displaced inferior lateral: 6 th ics aal Loud P 2, C 3 both ventricles Decrescendo diastolic murmur parasternally with ejection systolic murmur not radiating. No Austin Flint

Respiratory: n n Diffuse inspiratory crackles Distressed : tachypnoea, accessory muscle use. Abdomen: n No Hepatomegaly, No splenomegaly Urine Dipstix : n no microscopic hematuria

Problem List Infective Endocarditis Severe Aorta Regurgitation with signs of bi-ventricular failure Pulmonary edema with acute respiratory failure

Special investigation Bloods: n n n n 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

echo Aorta root diameter = 30 mm (normal) Aorta valve opening = 21 mm (normal) Vegetation on all three aorta cusps Pressure half time = 67 ms (<200 ms severe acute AR) Mitral valve : mild regurgitation Left Atrium : 4. 3 cm (enlarged) Left ventricle: LVEDD 6. 5 cm, LVESD 5 cm, LVEF = 44% Right heart mildly enlarged, mild TI, RVPSP = 65 mm. Hg

Treatment Furosemide 40 mg bd ivi Enalapril 5 mg bd po Elantin 20 mg bd po Pen G, Gentamycin, Cloxacillin, Diflucan Urgent cardio-thoracic consult n Ross procedure was done

Surgery in NVE Introduction n n 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) n Surgery is warranted for native valve IE who have one or more of the following w 1. Heart failure (moderate to severe) that is directly related to valve dysfunction. w 2. Severe aorta/ mitral regurgitation with evidence of abnormal hemodinamics, such as elevated LVED or left atrial pressures. w 3. Endocarditis due to fungal of high resistant organisms. w 4. Peri-valvular infection with abscess/ fistula formation

Other condition considered as possible indications n n 1. Embolic events while on appropriate antibiotic regimen or large vegetations (> 10 mm in diameter) 2. Large vegetations > 10 mm in diameter (even without embolic events) if mobile

Choice of procedure For active infection (2006 ACC/AHA): n Valve repair rather than replacement Only possible in minority of cases n Thus leaflet perforation without destruction or annular involvement.

Heart Failure Moderate to severe HF due to IE n n Medical therapy : mortality rate 75% Medical & surgical : mortality rate 25% HF is indication in 2/3 to ¾ of cases IE induced AR is more likely to produce HF than IE induced MR (death may occur suddenly in aorta involvement)

Caveats n Non cardiac factors that exaggerate HF w Fever, anemia, sepsis, renal insufficiency n Hx of previous HF. w HF out of proportion to valve dysfunction.

Complicated infection Persistent positive BC n 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 n 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 2 nd 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 (>1 cm) 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 emboli In general is not indicated for increase in vegetation size in patient responding well to medical Rx Vegetations > 10 mm 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): n n 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, 17 th Edition, 2008 Schick, EC, Surgery for native valve endocarditis, Uptodate, June 2008 Talley, NJ, O’Conner, S, Clinical examination, 2001

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