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Endocarditis: A Plague for the 21 st Century?

Mikel D. Smith, MD, FACC, FAHA, FASE Professor of Medicine UK Division of Cardiology Director, UK Echo Lab Gill Heart Institute Cardiovascular Grand Rounds September 24, 2009. Endocarditis: A Plague for the 21 st Century?. Patient: DBH. 42 yo Caucasian male

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Endocarditis: A Plague for the 21 st Century?

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  1. Mikel D. Smith, MD, FACC, FAHA, FASE Professor of Medicine UK Division of Cardiology Director, UK Echo Lab Gill Heart Institute Cardiovascular Grand Rounds September 24, 2009 Endocarditis: A Plague for the 21st Century?

  2. Patient: DBH • 42 yo Caucasian male • Presented 6/06/09 to OSH with fever, cough, shaking chills and malaise • History of alcohol and IV opioid abuse since 2000 • Chest x-ray revealed RLL pneumonia; blood cultures positive for MRSA • Echo positive for TV vegetations • Treated initially with Vanc/Gent • Transferred to UK on 6/17/09 (Day 11) due to persistent high fevers (> 102 deg) and pneumonia, with WBC > 20K

  3. UK Admission: 6/17/09 • Awake alert, intelligent man • Ht: 5’11” Wt: 150 lbs • Diaphoretic with temp of 98.7 • BP 110/70, resp rate 24/min • Increased JVP with a visible V wave • Gr 3/6 holosystolic murmur, along RSB • Nontender abdomen, non palp liver, no edema

  4. Admission CXR 6/17/09

  5. Transthoracic Echo: 6/18/09

  6. Hospital Course • ID consult: Switched to daptomicin and linezolid • Based on LV dysfunction (EF 40-50%): lisinopril and carvedilol started • BP intolerant to lisinopril • Continued to have daily am fevers and WBC 28K-gradually down to 13K; blood cultures neg from 6/22 • Week 2: CT of chest revealed recurrent pleural effusion and possible infarction, chest tube inserted • Tigecycline added on 6/26 • On 6/27 (day 21) severely dyspneic, pleural based L posterior rub, RV heave, and “to and fro murmur” • Temp > 102 deg

  7. Fever Timeline

  8. WBC Timeline

  9. CXR # 2 6/23/09

  10. CXR # 3 6/27/09

  11. Repeat TTE at bedside: 6/27

  12. Hospital Course • Multidisciplinary conference: ID, CT (Sat am, 6th floor) • Pt offered and agreed to surgery for TVR • Coronary angios – no significant disease • Pt went to operating room (Sat 1pm) ….

  13. Endocarditis in the 21st Century • Pt presentation • Definitions • Diagnosis • TTE vs TEE • Complications • Indications for surgery • Special circumstances • Pacemakers • Prosthetic valves • Outcome for our patient • UK data (2007- present) • Some thoughts about the “plague”

  14. Endocarditis: Scope of the problem • Approx 20,000 cases per year in US • 1 year mortality is as high as 50% • Thromboembolic events: 30 - 50% • Another 20% may be clinically silent • In-house complication rate – 80% • Neither the incidence or mortality have decreased in the last 30 yrs

  15. Clinical Findings in Endocarditis

  16. Stigmata of Endocarditis

  17. Pathophysiology of Endocarditis • Infection of the lining of the heart (endocardium) • Abnormal valve surface, from disease, degeneration, or “wear and tear” • High velocity flow- stenosis or regurg • Circulating bacteria (bacteremia)

  18. Portal of Entry: Introduction of organisms into the blood stream, seeding the valves • IV drug abuse • Implanted devices (valves, pacer wires, lines/catheters, IVs, closure devices, patches, grafts, fistulae) • Surgeries/ procedures • Dental procedures/ mouth infections • Chronic skin, respiratory, GI, GU, or Gyn infections

  19. EHJ: Aug 27, 2009

  20. Vegetations • Inflammatory cardiac valve lesions, composed of bacteria, WBCs, macrophages, fibrin, rouleaux, and edema • *Attached to the “flow side” of valves • Amorphous and irregular in shape

  21. Mitral Valve Veg with Perforation

  22. Echo Characteristics of Vegs • Shaggy, amorphous • Gray, not white (calcium) • Not linear • On the “flow surface” (LVOT for aortic, LA for mitral, and RV for VSD) • Independent motion (with blood flow) • Tips of the leaflets • Seen in multiple views • Sewing rings of prosthetic valves

  23. Example of a large MV vegetation

  24. Risk Factors for Embolization • Occurs in 22-50% of infective endo • 1st two weeks of therapy • Mitral vegetations – esp. AMVL • > 10 mm vegetations • Previous embolization

  25. Why are they called Vegs?

  26. Importance of Echo Findings • Establish the diagnosis (modified Duke criteria) • Which valves? (MV > Ao > TV >> PV) • Prognosis: worse for Ao > MV • Embolic potential: size (> 10 mm) and mobility • Detect valve dysfunction (regurg, flail) • Evaluate LV function (CHF) • Look for complications: flail, abscess, dehiscence

  27. Vegetation Size vs Complications

  28. Flail PV Leaflet

  29. Definite Echo Criteria • Definite vegetation • Mobile, echodense mass attached to the valve or endocardium, in the trajectory of regurgitant jet • Or on prosthetic material • With no other anatomical explanation • New valvular regurgitation • Abscess • New dehiscence of a prosthesis or ring

  30. Differential Diagnosis of Valve Lesions • Degenerative change, “thickening” • Caseous necrosis, degenerative calcification (CMA) • Lambl’s excrescences (fibrin strands) • Bacterial endocarditis • Rheumatic inflammation, scar • Myxomatous changes (MVP) • Torn chordae tendinae • Papillary fibroelastoma, rhabdomyoma, myxoma • Loeffler’s endocarditis (eosinophilic) • Marantic (nonbacterial) endocarditis • Surgical sutures, pledgets

  31. “Masqueraders” of vegetations CMA Lambl’s

  32. Revised Duke Criteria2 major or 1 major + 3 minor • Major: • Positive Echo • Multiple positive blood cultures (with appropriate organism) • Minor: Predisposition Fever Thromboembolism Suggestive echo Immunologic phenom Suggestive micro

  33. TTE vs TEE • TTE sens is 80-90% with adequate quality images (42-79% in recent studies) • TEE is higher (> 90%), but semi-invasive • Mortality from TEE is 1:10,000 • * TEE is indicated if TTE is “non-diagnostic” (technically difficult/poor quality pictures) • TEE indicated as the initial imaging modality in prosthetic valves ( especially MVR)

  34. Causes of False Negative TTE • Early in the course of disease • Prosthetic material (mechanical valves, pacer wires, catheters • Small vegetations (1-2 mm) • Inexperienced readers • Technically difficult or suboptimal echoes

  35. Imaging “Tricks” for Sonographers and Echocardiographers • Be a CSI: look closely in pts with fever, bacteremia • Watch the flow side! esp. during valve closure • Zoom, Zoom, Zoom • Multiple views (SAX and Subcostal) • Review the study (in slow speed) • Adjust the gain for “gray” (compression) • Regurgitation is important • Search the shunts and prostheses carefully

  36. Investigate the Findings

  37. Use of Echo in IE EHJ: Aug 27, 2009

  38. Prosthetic Valve Endocarditis-A special circumstance • Lifetime risk is approximately 6% • Embolism is common • TTE assessment is helpful (esp AoV), but not diagnostic • Echo tip-offs: • Dehiscence – rocking of the sewing ring • * New, eccentric or paravalvular leak • Hemolysis or jaundice

  39. Prosthetic Valve Endocarditis:TEE is superior TTE TEE

  40. Another circumstance: Infected Pacemaker Lead or Catheter

  41. Complications: Definitions EHJ: Aug 27, 2009

  42. MV Annular Abscess

  43. Perforation of TV leaflet with flail

  44. Ao-LA Fistula via the “curtain”

  45. Prosthetic Valve Dehiscence: Paravalvular AR and Rocking of the Sewing Ring

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