Infective Endocarditis Airley E. Fish, MD Echo Conference January 16, 2008.
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Transcript of Infective Endocarditis Airley E. Fish, MD Echo Conference January 16, 2008.
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Infective Endocarditis
Airley E. Fish, MD
Echo Conference
January 16, 2008
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Outline
• Definition• Epidemiology/Predisposing factors• Microbiology• Clinical manifestations• Cardiac complications• Diagnosis• Indications for TTE vs TEE• Treatment• Indications for surgery• Prognosis – mortality & relapse rates• Indications for antibiotic prophylaxis
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Definition• Microbial infection of
endocardium• Vegetation
– Platelets– Fibrin– Microorganisms– Inflammatory cells
Images from www.escuela.med.puc.cl
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Vegetation – Gross & Microscopic
Large, friable vegetation on the mitral valve
Low power view of endocardium & myocardium, showing a fibrin vegetation on the endocardial surface. Endocardium appears edematous & inflamed
Images from www.pathology.vcu.edu
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Definition
• Location– Predominantly heart
valves, but can occur on/in:• Septal defects
• Chordae tendinae
• Mural endocardium
• Acute vs sub-acute/chronic– Temporal – Severity of clinical
presentation– Progression of untreated
disease
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Conditions Predisposing to IE
• Factors altering immunity:– Immunosuppression– Diabetes– Chronic alcoholism
• Structural cardiac abnormalities:– AS, AR– Bicuspid aortic valve– MS, MR– Senile mitral ring calcification
• Factors causing bacteremia:– Dental work/Poor dental hygiene– IVDU– GU/GI procedures
• External factors:– Mechanical valves– Indwelling vascular catheters– Pacing wires (IV)
Modified from David M. Leder Echo Conference 01/07
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Epidemiology/Predisposing Factors
• IE of native valves
• IE of prosthetic valves
• Nosocomial IE
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Epidemiology/Predisposing Factors – Native Valves
• Incidence: 1.7-6.2 cases/100K person-years
• Gender: ♂ predominance (1.7:1)
• Age: > ½ of all cases occur in adults > 60– ↓ in incidence of RHD in post antibiotic era– ↑ in elderly
• ↑ degenerative valve disease • ↑ prosthetic valves• ↑ ‘ed exposure to nosocomial bacteremia
• History of infective endocarditis– Recurrence in 4.5% of large cohort of non-addicts
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Epidemiology/Predisposing Factors – Native Valves
• Structural heart disease– ¾ of patients have preexisting structural
cardiac abnormality– MVP most common– MVP + MR + thickened leaflets = 5-8 x
risk IE!
• Injection-drug use – Trend toward younger patients – Incidence of 150-2000 per 100,000
person years (higher if co-existent valvular disease)
– Most significant risk factor for R-sided endocarditis
• L-sided disease more common in addicts• S. aureus predominant organism• Vegetations often larger (i.e. > 1 cm)
– Injection cocaine > other drugs
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Epidemiology/Predisposing Factors – Native Valves
• HIV infection– S. aureus most frequent pathogen– Unusual organisms (e.g.
salmonella and listeria)– ?Independent risk factor for IE in
IVDA (unconfirmed)
• Other– Pregnancy– AV fistulas for HD– Central venous and PA catheters– Peritoneovenous shunts for
intractable ascites– Ventriculoatrial shunts for
hydrocephalus
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Epidemiology/Predisposing Factors – Prosthetic Valves
• Prosthetic heart valves– 7-25% of cases (likely to
↑ with aging population)– 1-4% of valve recipients
during the 1st year after replacement
– 1% per year thereafter– Risk IE mechanical >
bioprosthetic 1st 3 months– Equivalent risk @ 5 years
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Epidemiology/Predisposing Factors – Nosocomial IE
• Nosocomial endocarditis– 7-29% of all 3° care hospital cases– Dx >72 hours after admission with no evidence
of IE on admission or within 60 days of a prior admission if risk factor for bacteremia or IE during hospitalization
– Complication of bacteremia 2°• Invasive intravascular procedure• IV catheter-related infection
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Microbiology• S. aureus (32%)• Viridans group streptococci (18%)• Enterococci (11%)
– Frequently implicated in nosocomial bacteremia, but endocarditis rare
• Coagulase-negative staphylococci (11%)– Most common pathogen in early prosthetic
valve IE
• Culture negative endocarditis (8%)• Streptococcus bovis (7%)
– Common in elderly– Preexisting colonic lesions
• Other streptococci (5%)• Other organisms (3%)
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Microbiology• Fungi (2%)• HACEK - fastidious gram negative bacteria (2%)
– Haemophilus aphrophilus– Actinobacillus actinomycetemcomitans– Cardiobacterium hominis– Eikenella corrodens– Kingella kingae
• Non-HACEK gram-negative bacteria (2%)• Polymicrobial (1%)
– More common in association with IVDU
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Clinical Symptoms
• Fever (80%)
• Anorexia (75%)
• Chills (40%)
• Dyspnea (40%)
• Weight loss (25%)
• Night sweats (25%)
• Myalgias/arthralgias (15%)
Adapted from Mandell et al 2000 (Karmpaliotis) and Leder Echo Conference 2007
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Clinical Signs• Fever 90%
• Heart murmur 85%– Changing murmur (5-10%)– New murmur (3-5%)
• Peripheral manifestations 50%– Petechiae (20-40%)– Splinter hemorrhages (15%)– Osler nodes (10-20%)– Janeway lesions (< 10%)
• Splenomegaly 20-50%
• Septic complications 20%
• Clubbing 10-50%Adapted from Mandell et al 2000 (Karmpaliotis) and Leder Echo Conference 2007
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Common Peripheral Manifestations of IE• Splinter hemorrhages
– Under fingernails– Usually linear & red
• Conjunctival petechiae
• Osler’s nodes (ouch!)– Tender SQ nodules– Pulp of digits/thenar eminence
• Janeway lesions– Nontender, erythematous,
hemorrhagic, or pustular, often on the palms/soles .
Reference:Firsche,C. and others,Mitral-Valve Endocarditis,N Engl J Med.Vol. 345,NO.10,September6,2001,P739.
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Cardiac Complications
• CHF– 2° infection-induced valvular damage (AoV > MV)
• MI– 2° embolism of vegetation fragments → CHF
• Pericarditis – 2° coronary artery embolization → MI → pericarditis
• Extension beyond valve annulus– ↑ CHF, need for cardiac surgery, death
• Extension into septum– AV, fascicular, or BBB
• Erosion of mycotic aneurysm of sinus of Valsalva– Pericarditis, hemopericardium/tamponade, fistulas to R or L ventricle
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Diagnosis• Clinical• Laboratory
– (+) blood cultures– Non-specific findings
• Anemia• Leukocytosis• Abnormal UA• ↑’ed ESR & CRP
• Electrocardiographic– New AV block
• Moderately high PPV for formation of myocardial abscess, but sensitivity low
– New fascicular block– New BBB
• Suggestive of perivalvular invasion, particularly if AV IE
• Echocardiographic
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Diagnosis
• Duke criteria (clinical + laboratory + ECHO)– High specificity 99%– NPV > 92%
• Retrospective study 410 patients with IE– 72-90% agreement with ID expert assessment
• Most discrepencies 2º overly broad categorization of “possible” IE (experts rejected)
• Gave rise to “Modified Duke Criteria”
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Modified Duke Criteria
• Definite– 2 major– 1 major + 3 minor– 5 minor
• Possible– 1 major + 1 minor– 3 minor
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Modified Duke Criteria
• Major– Evidence of endocardial involvement with new
regurgitant murmur– Persistently (+) blood cultures– ECHO
• Discrete, echogenic, oscillating intracardiac mass located at site of endocardial injury
• Periannular abscess• New dehiscence of a prosthetic valve
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Modified Duke Criteria• Minor
– Predisposition to IE (certain cardiac conditions/IVDU)• High risk
– Prior IE– AoV– RHD – Prosthetic valve– Coarctation– Complex cyanotic congenital heart disease
• Moderate risk– MVP with MR +/- thickened leaflets– Isolated MS– Tricuspid valve disease– PS– HCM
• Low or no-risk– Secundum ASD– Ischemic heart disease– CABG– MVP without MR and thickened leaflets
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Modified Duke Criteria
• Minor– Fever > 38° C– Vascular phenomenon
• Aside from petechiae & splinter hemorrhages
– Immunologic phenomena• RF• GN• Osler’s nodes• Roth spots
– Microbiologic findings • (+) blood cultures that do not meet the major criteria
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Diagnosis - Echocardiography• Transthoracic – rapid, non-
invasive– ↑ Specificity 98%– Sensitivity 60-70%
• Challenging 2° obesity, COPD, chest wall deformities
• Transesophageal – more costly, invasive– Sensitivity 75-95%– Specificity 85-98%– NPV > 92%– Particularly useful if:
• Prosthetic valves• Evaluation of myocardial
invasion
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Echocardiography - Indications
• Pre-test probability of IE < 4%– TTE both cost effective & satisfactory for r/o IE
• Probability of IE 4-60%– TEE initially more cost effective, diagnostically
efficient• Unexplained bacteremia with GPC’s• Catheter-associated S. aureus bacteremia• Fever or persistent bacteremia with IVDU
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TEE > TTE
• Signs of perivalvular extension/presence of myocardial abscess– Fever or persistent bacteremia– Heart block– CHF– New pathologic murmur in patient with IE
• Spectral & color-flow Doppler on TEE demonstrate flow– Fistulas– Pseudoaneurysms– Unruptured abscess cavities– Valve perforations
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TEE > TTEAoV Regurgitation with Vegetation &
Valvular Destruction
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AoV Vegetation on TTE PLA
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AoV Vegetation TEE
Echodense mass attached to the noncoronary cusp of the AoV c/w a vegetation using TEE
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Mitral Valve Vegetation with Abscess
FIGURE 1. Mitral valve vegetation shown on transesophageal echocardiography. The echodense area at the annulus (arrow) is characteristic of underlying abscess.
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Multiple Vegetations AoV and MV
TTE PLA during diastole. Multiple vegetations on the anterior leaflet of the patient's mitral valve (arrows 1 and 2) and a 16 × 6 mm mobile vegetation on the aortic noncoronary cusp (arrow 3)
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M Mode TTE MV with Multiple Echoes from Vegetations
M-mode echocardiogram demonstrating multiple echoes from vegetations on the anterior leaflet of the MV during diastole. Specific sign of cusp vegetations in IE.
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Aspergillus Prosthetic Valve Endocarditis Causing Functional AS
Transesophageal echocardiography (TEE) was performed and revealed a 4 x 2 cm mass on the bioprosthetic AoV, encasing all three leaflets and severely limiting leaflet excursion (Figure 2). Doppler examination revealed a peak gradient of nearly 100 mmHg.
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Treatment
• IV antimicrobial therapy for 4-6 weeks– Dependent upon
pathogen– Native vs prosthetic valve
• PCN G +/- gentamicin• Nafcillin/oxacillin +/-
gentamicin• Vancomycin +/- gentamicin• Ceftriaxone
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Treatment
• Anticoagulation– Has not been shown to
prevent embolization– May ↑ risk of intracerebral
hemorrhage• S. aureus prosthetic valve IE
particularly susceptible
– Role of aspirin still under investigation
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Surgical Therapy for Native Valve IE: Class I Indication (All < LOE B)
• Valvular stenosis or regurgitation → CHF– Strongest indication– Mortality in med rx 56-86% vs 11-35% med rx/surgery
• Hemodynamics @ time of surgery principle determinant of operative mortality
• AR or MR with hemodynamic e/o:– ↑’ed LVEDP – ↑’ed LA pressures– Moderate to severe pulmonary artery systolic HTN
• IE 2° fungal or other highly resistant organisms – Pseudomonas, brucella, coxiella, candida, ?enterococci (no synergistic Rx)
• lE complicated by:– Heart block– Annular or aortic abscess– Destructive penetrating lesions
• Sinus of Valsalva to RA, RV, LA fistula• Mitral leaflet perforation with AoV endocarditis• Infection in annulus fibrosa
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Surgical Therapy for Native Valve IE: Other Indications (Both LOE C)
• Class IIa– Recurrent emboli & vegetations despite ABX
• Class IIb– Mobile vegetations > 10 mm with or without emboli
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Surgical Therapy for Prosthetic Valve IE: Class I Indication (All LOE < B)
• Consultation with a cardiac surgeon
• Heart failure
• Dehiscence via cine-fluoroscopy or ECHO
• ↑ obstruction or regurgitation
• Complications (e.g. abscess formation)
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Surgical Therapy for Prosthetic Valve IE: Other Indications (All LOE C)
• Class IIa– Persistent bacteremia/recurrent emboli despite ABX
• If cerebral infarcts, risk of worsening neurological deficits dependent upon time from initial embolus until surgery
• < 7 days, 8-14 days, > 4 weeks (44%, 16.7%, 2.3%)
– Relapsing infection
• Class III– Not indicated if uncomplicated IE 2° 1st time
infection with a sensitive organism
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Mortality Rates
• Vary according to:– Causative microorganism
• > 50 % pseudomonas• 25-47% S. aureus • 15-25% enterococci• 5-37% Q-fever• 4-16% Strep viridans
– Presence of complications or coexisting conditions• CHF, neuro events, renal failure, severe immunosuppression 2° HIV
– Development of perivalvular extension/myocardial abscess– Use of combined medical and surgical Rx in appropriate
patients– Death 2° CNS embolic events/hemodynamic deterioration
• Native-valve/prosthetic valve as high as 20-25%• R-sided IE in IVDU approximately 10%
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Relapse Rates
• Usually occurs within 2 months of DC’ing ABX• Native valve
– PCN-sensitive strep viridans < 2%– Enterococcus 8-20%– S. aureus, enterobacter, fungi
• Rx failure during 1° course of ABX
• Prosthetic valve– 10-15%– (+) blood culture at time of valve replacement RF for relapse,
particularly if staphylococcus endocarditis
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Procedures That May Result in Transient Bacteremia
• Dental– Manipulation of gingival tissue or periapical region of teeth
• Respiratory tract– Incision or biopsy of respiratory tract mucosa (e.g.
tonisillectomy, bronchoscopy with biopsy)• GI/GU tract
– No longer considered high risk – no prophylaxis, unless active GI/GU infection
• Skin/Musculoskeletal tissue– If polymicrobial infection undergoing a surgical procedure
• Pregnancy– Only in highest risk cardiac conditions undergoing vaginal
delivery
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Indications for Antibiotic Prophylaxis
• Prior history of IE• Prosthetic heart valves (including bioprosthetic &
homograft)• Unrepaired cyanotic congenital heart disease
– Including palliative shunts and conduits
• Completely repaired congenital heart defects with prosthetic material or device, whether placed by surgery or by catheter intervention during the 1st 6 months after the procedure
• Repaired congenital heart disease with residual defects at or adjacent to the site of the prosthetic device
• Cardiac valvulopathy in a transplanted heart
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Antibiotic Prophylaxis No Longer Needed
• Bicuspid AoV
• Acquired aortic or mitral valve disease including:– MVP with regurgitation– Prior valve repair
• HCM with latent or resting obstruction
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