1	Infective Endocarditis- Cardiologist Role ד"ר יורם נוימן בית חולים מאיר כפר-סבא
2	Infective Endocarditis- Cardiologist Role Diagnosis Management
3	Duke Criteria for the Diagnosis of Infective Endocarditis Major criteria Blood culture positive for infective endocaditis Evidence of endocardial involvement Oscillating intracardiac mass on a valve or supporting structure, in the path of regurgitant jets or on implanted material. Abscess New or partial dehiscence of a prosthetic valve New valvular regurgitation (worsening or changing of pre-existing murmur- not sufficient)
4	Duke Criteria for the Diagnosis of Infective Endocarditis Minor Criteria Predisposition- heart condition, IV abuse Fever (>38⁰C) Vascular phenomena Immunologic phenomena Atypical blood culture results
5	Clinical Criteria Definite Infective Endocarditis- 2 major criteria, or 1 major and 3 minor, or 5 minor possible Infective Endocarditis- 1 major and 1 minor, or 3 minor
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7	F בן 30, ספורטאי. התאשפז עקב כאבי חזה, ללא עדות לאיסכמיה. שבועיים טרם אישפוזו, עבר ברור בבי"ח אחר עקב חולשה וחוסר תחושה ביד שמאל תוך כדי ריצה. ב-CT מוח, ממצא החשוד כאוטם ב-capsula interna. ב-TTE, ממצא ע"פ המסתם האאורטלי.
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10	האבחנה?
11	"בת 82" בת 82 התאשפזה עקב חום 38.2, חולשה ובלבול. 3 תרביות עם צמיחה של Strep Gr A בברור עקב הדרדרות במצבה וללא מציאת מקור זיהומי- ב-TTE ללא עדות לאנדוקרדיטיס ב-TEE-
12	L
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14	האבחנה?
15	Characteristics Allowing a Valve Mass to Be Designated a Vegetation
16	Characteristics Allowing a Valve Mass to Be Designated a Vegetation
17	Characteristics Allowing a Valve Mass to Be Designated a Vegetation
18	Characteristics Allowing a Valve Mass to Be Designated a Vegetation
19	Characteristics Allowing a Valve Mass to Be Designated a Vegetation
20	Characteristics Allowing a Valve Mass to Be Designated a Vegetation
21	LMV בן 66 ברקע- מחלת לב איסכמית- עבר 3 אוטמים. בברור כאבי גב אובחנה אוסטאומיאליטיס של חוליות מותניות. עבר ניקוז ניתוחי (לא היתה צמיחה). במהלך לאחר הניתוח- בצקת ריאות. באקו-
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33	הטיפול
34	הטיפול
35	Complications of Infective Endocarditis CHF- Greatest impact on prognosis (regardless of its cause!). Therefore early surgery! The decision to delay surgery to extent the duration of preoperative antibiotic therapy should be discouraged. Powerful predictor of a poor outcome with surgical therapy as well….
36	Complications of Infective Endocarditis
37	Vegetation Size and Rate of Complications
38	Surgery for Native Valve Endocarditis Class I 1. Surgery of the native valve is indicated in patients with acute infective endocarditis who present with valve stenosis or regurgitation resulting in heart failure. (Level of Evidence: B) 2. Surgery of the native valve is indicated in patients with acute infective endocarditis who present with AR or MR with hemodynamic evidence of elevated LV end diastolic or left atrial pressures (e.g., premature closure of MV with AR, rapid decelerating MR signal by continuous-wave Doppler (v-wave cutoff sign), or moderate or severe pulmonary hypertension). (Level of Evidence: B) 3. Surgery of the native valve is indicated in patients with infective endocarditis caused by fungal or other highly resistant organisms. (Level of Evidence: B) 4. Surgery of the native valve is indicated in patients with infective endocarditis complicated by heart block, annular or aortic abscess, or destructive penetrating lesions (e.g., sinus of Valsalva to right atrium, right ventricle, or left atrium fistula; mitral leaflet perforation with aortic valve endocarditis; or infection in annulus fibrosa). (Level of Evidence: B). (ACC/AHA practice guidelines 2006)
39	Surgery for Native Valve Endocarditis Class IIa Surgery of the native valve is reasonable in patients with infective endocarditis who present with recurrent emboli and persistent vegetations despite appropriate antibiotic therapy. (Level of Evidence: C) Class IIb Surgery of the native valve may be considered in patients with infective endocarditis who present with mobile vegetations in excess of 10 mm with or without emboli. (Level of Evidence: C)
40	VAI בן 55, מעשן. מזה 5 ימים חום עד 39. עבר ניתוח ברך לפני 4 חודשים ומאז מספר אירועי חום שחלפו עצמונית. בלילה טרם קבלתו- כאב ראש חזק, חולשה בפלג גוף ימני. ב-CT- ממצא פריאטו-אוקסיפיטלי משמאל- באבחנה מבדלת בין אנצפליטיס לאוטם חריף. ב-TTE מסתם אאורטלי מסוייד ודולף ב-TEE-
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44	הטפול?
45	Surgery for Native Valve Endocarditis Class I 1. Surgery of the native valve is indicated in patients with acute infective endocarditis who present with valve stenosis or regurgitation resulting in heart failure. (Level of Evidence: B) 2. Surgery of the native valve is indicated in patients with acute infective endocarditis who present with AR or MR with hemodynamic evidence of elevated LV end diastolic or left atrial pressures (e.g., premature closure of MV with AR, rapid decelerating MR signal by continuous-wave Doppler (v-wave cutoff sign), or moderate or severe pulmonary hypertension). (Level of Evidence: B) 3. Surgery of the native valve is indicated in patients with infective endocarditis caused by fungal or other highly resistant organisms. (Level of Evidence: B) 4. Surgery of the native valve is indicated in patients with infective endocarditis complicated by heart block, annular or aortic abscess, or destructive penetrating lesions (e.g., sinus of Valsalva to right atrium, right ventricle, or left atrium fistula; mitral leaflet perforation with aortic valve endocarditis; or infection in annulus fibrosa). (Level of Evidence: B). (ACC/AHA practice guidelines 2006)
46	MA2
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54	הטיפול?
55	Surgery for Native Valve Endocarditis Class I 1. Surgery of the native valve is indicated in patients with acute infective endocarditis who present with valve stenosis or regurgitation resulting in heart failure. (Level of Evidence: B) 2. Surgery of the native valve is indicated in patients with acute infective endocarditis who present with AR or MR with hemodynamic evidence of elevated LV end diastolic or left atrial pressures (e.g., premature closure of MV with AR, rapid decelerating MR signal by continuous-wave Doppler (v-wave cutoff sign), or moderate or severe pulmonary hypertension). (Level of Evidence: B) 3. Surgery of the native valve is indicated in patients with infective endocarditis caused by fungal or other highly resistant organisms. (Level of Evidence: B) 4. Surgery of the native valve is indicated in patients with infective endocarditis complicated by heart block, annular or aortic abscess, or destructive penetrating lesions (e.g., sinus of Valsalva to right atrium, right ventricle, or left atrium fistula; mitral leaflet perforation with aortic valve endocarditis; or infection in annulus fibrosa). (Level of Evidence: B). (ACC/AHA practice guidelines 2006)
56	MAA בת 68 ברקע השמנת יתר, יל"ד, היפרליפידמיה. התאשפזה עקב חום, כאבי בטן ושלשול. במיון- הונשמה עקב אי ספיקה נשימתית. בתרביות דם- MSSA ב-TEE
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65	הטיפול?
66	Surgery for Native Valve Endocarditis Class I 1. Surgery of the native valve is indicated in patients with acute infective endocarditis who present with valve stenosis or regurgitation resulting in heart failure. (Level of Evidence: B) 2. Surgery of the native valve is indicated in patients with acute infective endocarditis who present with AR or MR with hemodynamic evidence of elevated LV end diastolic or left atrial pressures (e.g., premature closure of MV with AR, rapid decelerating MR signal by continuous-wave Doppler (v-wave cutoff sign), or moderate or severe pulmonary hypertension). (Level of Evidence: B) 3. Surgery of the native valve is indicated in patients with infective endocarditis caused by fungal or other highly resistant organisms. (Level of Evidence: B) 4. Surgery of the native valve is indicated in patients with infective endocarditis complicated by heart block, annular or aortic abscess, or destructive penetrating lesions (e.g., sinus of Valsalva to right atrium, right ventricle, or left atrium fistula; mitral leaflet perforation with aortic valve endocarditis; or infection in annulus fibrosa). (Level of Evidence: B). (ACC/AHA practice guidelines 2006)
67	ABA בת 87, דמנטית. CABG+AVR ב-1992 התקבלה עקב מחלה חום שנמשכה כ-5 ימים. בתרביות דם- Enterococci. TTE לא אבחנתי ב-TEE-
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71	הטיפול
72	Surgery for Prosthetic Valve Endocarditis Class I 1. Consultation with a cardiac surgeon is indicated for patients with infective endocarditis of a prosthetic valve. (Level of Evidence: C) 2. Surgery is indicated for patients with infective endocarditis of a prosthetic valve who present with heart failure. (Level of Evidence: B) 3. Surgery is indicated for patients with infective endocarditis of a prosthetic valve who present with dehiscence evidenced by cine fluoroscopy or echocardiography. (Level of Evidence: B) 4. Surgery is indicated for patients with infective endocarditis of a prosthetic valve who present with evidence of increasing obstruction or worsening regurgitation. (Level of Evidence: C) Surgery is indicated for patients with infective endocarditis of a prosthetic valve who present with complications, for example, abscess formation. (Level of Evidence: C) (ACC/AHA practice guidelines 2006)
73	Surgery for Prosthetic Valve Endocarditis Class IIa 1. Surgery is reasonable for patients with infective endocarditis of a prosthetic valve who present with evidence of persistent bacteremia or recurrent emboli despite appropriate antibiotic treatment. (Level of Evidence: C) 2. Surgery is reasonable for patients with infective endocarditis of a prosthetic valve who present with relapsing infection. (Level of Evidence: C) Class III Routine surgery is not indicated for patients with uncomplicated infective endocarditis of a prosthetic valve caused by first infection with a sensitive organism. (Level of Evidence: C) (ACC/AHA practice guidelines 2006)
74	SMA
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76	"בברור מקיף-"
77	בוצע TEE נוסף
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83	טיפול?
84	Surgery for Prosthetic Valve Endocarditis Class I 1. Consultation with a cardiac surgeon is indicated for patients with infective endocarditis of a prosthetic valve. (Level of Evidence: C) 2. Surgery is indicated for patients with infective endocarditis of a prosthetic valve who present with heart failure. (Level of Evidence: B) 3. Surgery is indicated for patients with infective endocarditis of a prosthetic valve who present with dehiscence evidenced by cine fluoroscopy or echocardiography. (Level of Evidence: B) 4. Surgery is indicated for patients with infective endocarditis of a prosthetic valve who present with evidence of increasing obstruction or worsening regurgitation. (Level of Evidence: C) Surgery is indicated for patients with infective endocarditis of a prosthetic valve who present with complications, for example, abscess formation. (Level of Evidence: C) (ACC/AHA practice guidelines 2006)
85	P בן 60 ברקע- השמנת יתר וקוצב לב קבוע. התאשפז עקב מחלת חום. בתרביות דם- MSSA TTE לא הדגים מקור זיהומי ב-TEE
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87	טיפול?
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89	Use of Echocardiography During Diagnosis and Treatment of `Endocarditis Early x Echocardiography as soon as possible (<12 h after initial evaluation) TEE preferred; obtain TTE views of any abnormal findings for later comparison TTE if TEE is not immediately available TTE may be sufficient in small children Repeat echocardiography TEE after positive TTE as soon as possible in patients at high risk for complications TEE 7–10 d after initial TEE if suspicion exists without diagnosis of IE or with worrisome clinical course during early treatment of IE
90	Use of Echocardiography During Diagnosis and Treatment of `Endocarditis Intraoperative x Prepump Identification of vegetations, mechanism of regurgitation, abscesses, fistulas, and pseudoaneurysms Postpump Confirmation of successful repair of abnormal findings Assessment of residual valve dysfunction Elevated afterload if necessary to avoid underestimating valve insufficiency or presence of residual abnormal flow Completion of therapy Establish new baseline for valve function and morphology and ventricular size and function TTE usually adequate; TEE or review of intraoperative TEE may be needed for complex anatomy to establish new baseline
91	Echocardiographic Features That Suggest Potential Need for Surgical Intervention Vegetation x Persistent vegetation after systemic embolization Anterior mitral leaflet vegetation, particularly with size >10 mm 1 embolic events during first 2 wk of antimicrobial therapy Increase in vegetation size despite appropriate antimicrobial therapy*
92	Echocardiographic Features That Suggest Potential Need for Surgical Intervention Valvular dysfunction x Acute aortic or mitral insufficiency with signs of ventricular failure Heart failure unresponsive to medical therapy Valve perforation or rupture Perivalvular extension Valvular dehiscence, rupture, or fistula New heart block Large abscess or extension of abscess despite appropriate antimicrobial therapy