Infective Endocarditis

CHALLENGING ISSUES IN INFECTIVE
ENDOCARDITIS
ISKANDER AL-GITHMI, MD, FRCSC

Consultant Cardiothoracic Surgeon
Assistant Professor of Surgery
King Abdulaziz University
CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS
Endocarditis Milestones
1885 - Clinical syndrome; described by Sir William
Osler.
It is of use, from time to time, to take stock, so to speak of
our knowledge of a particular disease, to see exactly
where we stand in regards to it, to inquire to what
conclusion the accumulated facts seem to point and to
ascertain in what direction we may look for fruitful
investigation in the future.I propose to do this in the
case of that most interesting disease known as ulcerative
endocarditis.
1944 - Penicillin (Alexander Fleming)

1981 - Von Reyn Criteria [Persistant bacteremia, New
regurgitant murmur and vascular Complications]
1994 - Dukes Criteria proposed by Dr. Durack from
Duke University.
Background
Despite improvement in health care and advancement in
diagnostic technology and therapy; the incidence of
infective endocarditis has not decreased over the past
decades.
Progressive evolution in risk factors:
- i.e. i.v. drug use
- Use of prosthetic valve
- Growing resistant micro-organisms.
Incidence of Infective endocarditis ~ 15000 to 20,000 new
cases per year.
Infective endocarditis classifications:

Native valve endocarditis: associated with congenital
heart disease and chronic rheumatic heart disease.
Prosthetic-valve endocarditis:
1-5% of individual with infective endocarditis have PVE
Early-PVE: infection within 60 days of surgery
Late -PVE: infection 2-6 months of surgery
Infective endocarditis in intravenous drug user

- Common in young population
- Tricuspid valve involved in up to 50% of cases
- Predominant pathogenes usually staph aureus
Important iatrogenic risk
endocarditis - hemodialysis
factors
for
infective
- 3 times more frequent than in general population

- Predominant pathogenes is staph aureus.
Pathogenesis
Bacterial adherence to damaged valve:
- Mechanical lesions
- Inflammatory lesions
Diagnosis Pre-requisite
High index of suspicious
Early TEE: High sensitivity 75-95%
Specificity 85-98%
Duke Clinical Criteria

Definite IE
Pathological criteria
Microorganisms:
demonstrated by culture or histology in a vegetation,

in a vegetation that has embolized, or in an intracardiac
abscess, or
Patological lesions: vegetation or intracardiac abscess present, confirmed

by histology showing active endocarditis
Clinical Criteria, using specific definitions listed in Table 2
2 major criteria or
1 major and 3 minor criteria, or
5 minor criteria
Possible IE
Findings consistent with Ied that fall short of "Definite" but not "Rejected"
Rejected
Firm alternate diagnosis for manifestation of endocarditis, or
Management Strategies
It is multi-disciplinary and team work
- Cardiologist
- Echo Cardiologist
- Cardiac Surgeon
- Infectious Disease
- Neurologist
Echocardiography in infective endocarditis

Extremely important not only to make diagnosis but for
early detection of potential complications.
Major Complications
- Thrombo-embolism
- Heart Failure
- Peri-annular extension of infection and
annular dehiscence
Thrombo-embolism
Major 30 40%
Rate 50%
Sub-clinical 10-20%
Up to 65% of embolic event involve CNS
90% of CNS embolism lodge in the distribution of middle
cerebral artery.
More than 90% of embolization developed within the 1st 3
weeks of the diagnosis of infective endocarditis
The rate of embolization decreased overtime during antimicrobial therapy.
Results of Previous Studies

Author (ref.)
Lutas et. al. (3)
Mugge et. al. (14)
Relation Between EEs Patients Embolic Events

and Vegetation Size
(n)
(%)
Echocardiography
Detected Vegetations
(%)
Embolic Events
During Therapy
Negative
77
22
TTE
56
ND
Positive
105
31
TTE
91
19
TEE biplane
Jaffe et. al. (16)
Negative
70
43
TTE
78
16
Sanfilippo et. Al. (13)
Positive
204
33
TTE
75
ND
Steckelberg et. al. (1)
Negative
207*
13
TTE
38
13
Rohmann et. Al. (15)
Positive
118
26
TEE biplane
42
21
Heinle et. al. (17)
Negative
41
49
TTE
73
49
Positive, >20 mm
106
35
TEE biplane
92
ND
80
44
75
Werner et. al. (23)

De Castro et. al. (12)
Present study
TEE monoplane (28%)

Negative
57+
44
TTE
TEE multiplane
Positive
176
37
TEE multiplane
Echocardiography predicts
infective endocarditis.
embolic
events
in
Study design: Prospective

Patients: 178 Consecutive patients with definite
diagnosis of infective endocarditis
All had multi-plane TEE
Results of Univariate and Multiple Stepwise Logistic Re

Multivariate Analysis
Univariate
p Value
p Value
Exp B
95% CI
0.007
NS
0.06
1.07
1.01-1.13
<0.0001
0.03
2.05
0.37
2.28-26.57
0.001
0.0011
Mitral valve vegetation
NS
NS
Aortic valve vegetation
NS
NS
Right valve vegetation
0.014
NS
NS
NS
0.023
NS
Presence of vegetation
Vegetation length
Vegetation mobility
Multiple valve vegetation

Staphylococcal IE
CI = confidence interval; IE = infective endocarditis; NS = not significant
Clinical Implications of the Study

The presence of vegetation visualized
echocardiogram is a predictive of embolism
by
The morphological characteristic of vegetations are

very helpful in predicting the embolic events.
What is the time interval required for

surgical intervention in infective
endocarditis?
Presence of vegetations is a strong indication for

surgical intervention, irrespective of valve
destruction, heart failure or response to antimicrobial therapy.
Embolic events is extremely high in the early
stage of the disease.
Embolic events can occur up to 20% of cases
from vegetation less than 10mm.
Congestive Heart Failure (CHF)

CHF may develop insidiously, despite appropriate
antibiotics as a result of progressive valvular insufficiency
and ventricular dysfunction.
CHF in infective endocarditis; portends a grave prognosis
with medical therapy.
Delaying surgery to the point of ventricular
decompensation dramatically increase operative mortality
from 6% to 11% for patient without CHF, 17-33% for
patient with CHF.
Periannular extension of infection and annular dehiscence

- Extension of infective endocarditis beyond
the valve annulus predict higher mortality,
more frequent development of CHF and the
need for surgical intervention.
- It occurs in 10-40% of all native-valve
endocarditis and 56% to 100% in PVE.
Management Approach to Infective

Endocarditis
Surgical versus medical therapy in
active complicated native valve
infective endocarditis.
Indications for Surgery (Group A) and Criteria for Inclusion in Gro
Group A
(23 patients)
n
%
Group B
(85 Patients)
n
%
CHF (Class III and IV, NYHA)
18
78
63
74
NS
Persistent Infection
11
48
29
34
NS
Persistent Systemic Hypotension
13
10
12
NS
Root Abscess
NS
Pericarditis
NS
CHF = congestive heart failure; NYHA = New York Heart Association; NS - not significant
p Value
Site of Involvement by Endocarditis

Group A
(23 patients)
n
%
Group B
(85 Patients)
n
%
p Value
Mitral
22
32
38
NS
Aortic
14
61
28
33
<0.05
Mitral + Aortic
17
19
22
NS
Mitral + Aortic + Tricuspid
...
...
Mitral + Tricuspid
...
...
Aortic + Tricuspid
...
...
NS=not significant; PDA=patent ductus arteriosus; VSD=ventricular septal defect
*For group comparison, p=0.079
Conclusions
Despite improvement in healthcare and major advance in
the diagnostic technology as well as medical-surgical
therapies, endocarditis has not decreased but new risk
factors have evolved.
Treatment of this infection require a multidisciplinary
approach.
Early surgery is critically important and maybe the only
best option in patients with infective endocarditis
irrespective of heart failure, valve destruction and
response to antimicrobial therapy.
New clinical research studies should be used to provide
definite answers to several remaining questions about this
complex infection.

Infective Endocarditis

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CHALLENGING ISSUES IN INFECTIVE

ISKANDER AL-GITHMI, MD, FRCSC

CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS

CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS

1944 - Penicillin (Alexander Fleming)

CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS

CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS