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Endocardite Infectieuse : Rôle de l’Echocardiographie

Endocardite Infectieuse : Rôle de l’Echocardiographie. 21 ème Congrès du Collège National des Cardiologues Français Paris, 8-10 octobre 2009. Jean-Luc MONIN, CHU Henri Mondor, Créteil Remerciements: Pr. Gilbert HABIB, CHU La Timone, Marseille. Role of Echocardiography

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Endocardite Infectieuse : Rôle de l’Echocardiographie

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  1. Endocardite Infectieuse : Rôle de l’Echocardiographie 21ème Congrès du Collège National des Cardiologues Français Paris, 8-10 octobre 2009 Jean-Luc MONIN, CHU Henri Mondor, Créteil Remerciements: Pr. Gilbert HABIB, CHU La Timone, Marseille

  2. Role of Echocardiography in Infective Endocarditis • Diagnosis • Management

  3. Role of Echocardiography in Infective Endocarditis • Diagnosis • Management

  4. Modified Duke criteria for the diagnosis of Infective Endocarditis • MAJOR CRITERIA: • - Blood cultures positive for IE • - Echocardiography positive for IE: vegetation, abscess, new valvular regurgitation/ dehiscence of prosthetic valve • MINOR CRITERIA: • - Predisposing heart condition, IV drug abuse • - Fever (> 38°C) • - Vascular phenomena: arterial emboli, mycotic aneurysms, intracranial hemorrhage, … • - Immunologic phenomena: Osler’s nodes, Roth’s spots, … • - Bacteriological evidence: Positive blood culture but does not meet major criteria Li et al. Clin Infect Dis.2000; 30: 633-8

  5. Clinical Suspicion of IE Trans-thoracic Echocardiography Prosthetic Valve Intracardiac device Poor quality TTE Positive TTE TTE Negative Clinical suspicion of IE High Low Transesophageal Echocardiography * Stop If initial TEE is negative but suspicion for IE remains, repeat TEE within 7-10 days Habib et al. ESC Guidelines. Eur Heart J.2009. Aug 27

  6. Diagnosis of Infective Endocarditis by Echo: Difficulties are frequent… • Diagnosis of vegetation • Diagnosis of abscess • IE affecting intra-cardiac devices

  7. Diagnosis of Infective Endocarditis by Echo: Difficulties are frequent… • Diagnosis of vegetation • Diagnosis of abscess • IE affecting intra-cardiac devices

  8. Diagnostic value for detecting vegetations: TTE versus TEE - In 80 cases of endocarditis, sensitivity for the detection of vegetation was 58% for TTE versus 90% for TEE (p= 0.001). Mugge et al. J Am Coll Cardiol.1989; 14: 631-8 * P= NS : TTE versus TEE Monin et al. J Am Coll Cardiol.2005; 46: 302-9

  9. Henri Mondor Apical 4-chamber view Nunes

  10. Henri Mondor Apical 4-chamber (Lower plane) Nunes

  11. Henri Mondor Color Flow Doppler Commissural leak (C2) Nunes

  12. Clinical Suspicion of IE Trans-thoracic Echocardiography Prosthetic Valve Intracardiac device Poor quality TTE Positive TTE TTE Negative Clinical suspicion of IE High Low Transesophageal Echocardiography * Stop If initial TEE is negative but suspicion for IE remains, repeat TEE within 7-10 days Habib et al. ESC Guidelines. Eur Heart J.2009. Aug 27

  13. Henri Mondor TEE : Inter-commissural plane Nunes

  14. Henri Mondor Inter-commissural plane + CFD Nunes

  15. Echocardiography (even Transesophageal) is not 100% sensitive • Very small (< 2 mm) vegetation • Non vegetant endocarditis • Prosthetic and pacemaker endocarditis • Mitral valve prolapse with thickened valves • Vegetation not yet present or already embolized A negative TEE does not rule out endocarditis If initial TEE is negative but suspicion for IE remains, repeat TEE within 7-10 days Habib et al. ESC Guidelines. Eur Heart J.2009. Aug 27

  16. Diagnosis of Infective Endocarditis by Echo: Difficulties are frequent… • Diagnosis of vegetation • Diagnosis of abscess • IE affecting intra-cardiac devices

  17. Abscess of the aortic root - Better assessed by TEE - Multiple views to assess abscess extension - Difficult diagnosis at the early stage of the disease - Need for frequent TEE controls if non operated Courtesy: Pr. C. Tribouilloy

  18. Abscess of the aortic root: Better assessed by TEE Courtesy: Pr. C. Tribouilloy

  19. Abscess of the aortic root: Better assessed by TEE Courtesy: Pr. C. Tribouilloy

  20. Diagnosis of Infective Endocarditis by Echo: Difficulties are frequent… • Diagnosis of vegetation • Diagnosis of abscess • IE affecting intra-cardiac devices

  21. Prosthetic valve endocarditis - Better assessed by TEE - Especially in the mitral position - Reverberations/ artifacts due to the prosthesis - Need for frequent TEE controls if non operated Postoperative D-45

  22. Prosthetic valve endocarditis: The role of Transesophageal Echo Postoperative D-45

  23. Prosthetic valve endocarditis: Repeat TEE if non operated Adapted antibiotics (D+10)

  24. Prosthetic valve endocarditis Adapted antibiotics (D+10)

  25. Role of Echocardiography in Infective Endocarditis • Diagnosis • Management

  26. Timing of Surgery in Infective Endocarditis: The 2009 ESC Guidelines

  27. Timing of Surgery in Infective Endocarditis: Indications for Uncontrolled Infection ESC Guidelines. Eur Heart J.2009. Aug 27

  28. Emergent surgery (the same day): Acute severe AR with pulmonary oedema Early mitral closure

  29. Emergent surgery (the same day): Acute severe AR with pulmonary oedema Diastolic MR

  30. Acute severe AR with pulmonary oedema : Limitations of the PHT

  31. Timing of Surgery in Infective Endocarditis: Indications for Heart Failure ESC Guidelines. Eur Heart J.2009. Aug 27

  32. Risk of systemic embolism according to Vegetation size (TEE) 178 patients, definite IE 30/43 10/24 % Embolic events 17/66 9/45 Di Salvo et al. J Am Coll Cardiol.2001; 37: 1069-76

  33. Risk of systemic embolism under appropriate antibiotics • 384 patients with definite IE , European multicentre study • Embolic events: n= 131 (34%), of which 28 (7.3%) under therapy • Under therapy: 20 events (71.4%) during the first 15 days % New Embolic Events Thuny et al. Circulation.2005; 112: 69-75

  34. Risk of systemic embolism under appropriate antibiotics • 629 cases of IE, 133 embolic events (21.1 %) • THE RISK OF EMBOLIC EVENTS: • Dramatically decreases after initiation of ATB • Remains high during the first 2 weeks of ATB • Is related to the size /mobility of the vegetations • May be reduced by early surgery ? Fabri et al. Int J Cardiol. 2006 ; 110 : 334-9

  35. Timing of Surgery in Infective Endocarditis : Prevention of embolism ESC Guidelines. Eur Heart J.2009. Aug 27

  36. Isolated large vegetation > 15 mm: Urgent surgery is required (Class IIb)

  37. Take-Home messages • Echocardiography plays a key role in the diagnosis and management of patients with infective endocarditis • Transesophageal echo is mandatory in the majority of patients • A negative TEE does not rule out endocarditis: repeat TEE after 7-10 days if suspicion if IE remains • Early indications for surgery (CHF, uncontrolled infection or prevention of embolism) are mainly based on echocardiography (TEE ++)

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