Infective endocarditis:

Clinical case

Nina Ajmone Marsan, MD, PhD

73 year-old man

Known with:

• Hypertension (therapy with amlodipine and doxazosine)

• COPD GOLD II (therapy with prednisone)

• Chronic anemia by myelodysplasia

• 2013: PTA arteria iliaca communis (therapy with ASA)

• Cardiac murmur due to moderate aortic stenosis: asymptomatic

Episode of flu (myalgia, arthralgia, fever, headache)

After 2 weeks no fever anymore but severe back-pain and general

unwellness

Hospitalized in a peripheral hospital:

• No signs of decompensation, Splinter haemorrhage, subfebriel

• Increased inflammatory parameters: CRP 138 mlg/L, ESR 66 mm/h,

Hb 5.4 mmol/L, leukocytes 12.9 10<9/L

• BNP: 50 pmol/L, Creatinine 136 micromol/L, MDRD 45 ml/min/1.73m2

• Two blood culture positive for streptococcus gallolyticus

• Started therapy with benzylpennicilline ev

During hospitalization of 2 weeks:

Persistent increased inflammatory parameters despite

antibiotic therapy,

Bordeline fever with only once 38.4°C

Blood culture still positive for Str. Gallolyticus

CT scan thorax and abdomen:

Pleura-effusion

Small abscess of left ileopsas muscle

Diffuse severe calcification of thoracic aorta

FDG-PET scan:

no clear endocarditis focus

Possible abscess left ileopsoas muscle

Pleura-effusion without FDG accumulation

Thorax CT scan

FDG-PET scan

First contact with the endocarditis team for surgical

options

Patient transferred to our

tertiary Center

Repeated blood culture

negative for S. Gallolyticus

Development of pneumonia

started cefuroxim

stopped because of

progressive renal dysfunction

Endocarditis team decision:

Not operable

Too high risk operation

Euroscore 64%

Development of complete AV block for which reanimation

Afterwards significant neurological damage (coma)

According to neurologist not compatible with the reanimation.

Maybe embolic? Decision not to perform CT scan

Patient deceased after 1 day

What do the guidelines say?

Reasons for update

New algorithms for diagnosing IE

Multimodality imaging

Role of Endocarditis Team

Antibiotic prophylaxis unchanged!

Emphasis on the three “Es”:

Early diagnosis, Early therapy, Early surgery

Could we have prevented it?

What do the guidelines say?

NO!

Cardiac conditions at highest risk of IE for which prophylaxis should be considered when a high-risk procedure is performed

Emphasis on advise for dental hygiene!

Early diagnosis?

What do the guidelines say?

Diagnosis of Infective Endocarditis

Signs of InfectionSigns of embolism

(some are immunological)Signs of cardiac

disorder

Fever (90%) Pulse loss Murmur

Night sweats Stroke New murmur

Arthralgia Myocardial infarction Heart failure

Myalgia Unilateral blindness

Anaemia Haematuria

Weight loss Petechiae

Clubbing Splinter haemorrhage

Splenomegaly Osler nodes

Glomerulonephritis Jeneway lesions

“The classic Triad”

Role of Imaging

Diagnosis of IEESC 2015 modified criteria

Definite: 2 Major or 1 Major+3 minor

or 5 minor

Possible: 1 Major + 1 minor

or 3 minor

Rejected: Firm alternative,

symptom resolution, no path evidence

Diagnostic algorithm for IEESC 2015 modified criteria

Early therapy?

Timely referred patient to

Endocarditis Team/Centre?

What do the guidelines say?

IIa / B

IIa / B

Predictors of poor outcome

Early surgery?

What do the guidelines say?

www.escardio.org

2424

Indications and timing of surgery in left-sided valve IE

European Heart Journal (2015) doi:10.1093/eurheartj/ehv319

Indications for surgery Timing Class Level

1. Heart Failure

Aortic or mitral NVE or PVE with severe acute regurgitation,obstruction or fistula causing refractory pulmonary oedema or cardiogenic shock.

Emergency I B

Aortic or mitral NVE or PVE with severe regurgitation or obstruction causing symptoms of HF or echocardiographic signs of poor haemodynamic tolerance.

Urgent I B

2. Uncontrolled infection

Locally uncontrolled infection (abscess, false aneurysm, fistula, enlarging vegetation).

Urgent I B

Infection caused by fungi or multiresistant organisms. Urgent/elective I C

Persisting positive blood cultures despite appropriate antibiotic therapy and adequate control of septic metastatic foci.

Urgent IIa B

PVE caused by staphylococci or non-HACEK Gram negative bacteria. Urgent/elective IIa C

3. Prevention of embolism

Aortic or mitral NVE or PVE with persistent vegetations >10 mm after one or more embolic episode despite appropriate antibiotic therapy.

Urgent I B

Aortic or mitral NVE with vegetations >10 mm, associated with severe valve stenosis or regurgitation, and low operative risk.

Urgent IIa B

Aortic or mitral NVE or PVE with isolated very large vegetations (>30 mm).

Urgent IIa B

Aortic or mitral NVE or PVE with isolated large vegetations(>15 mm) and no other indication for surgery.

Urgent IIb C

www.escardio.org European Heart Journal (2015) doi:10.1093/eurheartj/ehv319

25

Therapeutic strategy for patients with IE and neurological complications

European Heart Journal (2015) doi:10.1093/eurheartj/ehv319

Neurological complication

• Clinical assessment• Cerebral CT scan / MRI• TTE / TOE

• Heart failure• Uncontrolled infection• Abscess• High embolic risk

• Intracranial haemorrhage• Coma• Severe comorbilities• Stroke with severe damage

Consider surgeryConservative treatment

and monitoring

Yes

Yes

No

No

Controversial issues:

• Late development of peri-annular abscess?

• Mobile aortic plaque or vegetation? Embolic

risk?

• Patient inoperable since the beginning?

• Operative risk assessment…new score?

What do the guidelines say?