endocarditis & infections of the heart

Endocarditis &Endocarditis & Infections of the Heart Infections of the Heart

Nausheen Akhter, MDNausheen Akhter, MDCore CurriculumCore CurriculumMarch 4, 2008March 4, 2008

ContentsContents

Epidemiology and MicroorganismsEpidemiology and Microorganisms

PathophysiologyPathophysiology

Clinical FeaturesClinical Features

Diagnosis and TreatmentDiagnosis and Treatment

Prevention and GuidelinesPrevention and Guidelines

Other Infections: Bacterial Pericarditis, Infected DevicesOther Infections: Bacterial Pericarditis, Infected Devices

Infective Endocarditis (IE)Infective Endocarditis (IE)

IE is an infection of the endothelial lining of the IE is an infection of the endothelial lining of the heart valves, mitral or tricuspid chorda tendinea, heart valves, mitral or tricuspid chorda tendinea, valve annulus, and aortic root.valve annulus, and aortic root.

Pre-existing heart disease is found in 2/3 of the Pre-existing heart disease is found in 2/3 of the cases of left-sided IE.cases of left-sided IE.

1/3 patients have normal or clinically 1/3 patients have normal or clinically unrecognized valve disease.unrecognized valve disease.

3.6 to 7.0 cases/100,000 patient-years3.6 to 7.0 cases/100,000 patient-years

EpidemiologyEpidemiologyAdults (%)Adults (%)

Predisposing Predisposing ConditionsConditions

15 - 60 yr15 - 60 yr > 60 yr> 60 yr

RHDRHD 25-3025-30 88

CHDCHD 10-2010-20 22

MVPMVP 10-3010-30 1010

DHDDHD RareRare 3030

IVDUIVDU 15-3515-35 1010

OtherOther 10-1510-15 1010

NoneNone 25-4525-45 25-4025-40

Braunwald 8th Edition

EpidemiologyEpidemiologyWho is at high risk for developing endocarditis?Who is at high risk for developing endocarditis?

People with prosthetic heart valves, previous People with prosthetic heart valves, previous incidents of endocarditis, complex congenital heart incidents of endocarditis, complex congenital heart disease, IVDU, and surgically devised systemic disease, IVDU, and surgically devised systemic pulmonary shunts.pulmonary shunts.

What patients have a moderate risk for What patients have a moderate risk for developing endocarditis?developing endocarditis?

Acquired valvular dysfunction, HCOM, and Acquired valvular dysfunction, HCOM, and uncorrected congenital defects.uncorrected congenital defects.

Zevitz, M. Pearls of Wisdom Board Review

EpidemiologyEpidemiology

Patient PopulationsPatient Populations MVP (7-30% of NVE not related to IVDU or MVP (7-30% of NVE not related to IVDU or

nosocomial infection)nosocomial infection)Risk is mostly in pts with thickened valve leaflets (>5mm) Risk is mostly in pts with thickened valve leaflets (>5mm) and MR murmur.and MR murmur.

MVP + murmur 52/100,000 vs. no murmur 4.6/100,000 person-MVP + murmur 52/100,000 vs. no murmur 4.6/100,000 person-yryr

RHDRHDMV > AVMV > AV

CHD (10-20% young adults, 9% older adults)CHD (10-20% young adults, 9% older adults)PDA, VSD, and biscupid aortic valve most commonPDA, VSD, and biscupid aortic valve most common

HIVHIVNot significant risk for IE, unless IVDUNot significant risk for IE, unless IVDU



Patient PopulationsPatient Populations IVDU (2-5%/patient-year)IVDU (2-5%/patient-year)

TV>MV>AV=multiple sitesTV>MV>AV=multiple sites

TV IE is associated with pleuritic chest pain, SOB, TV IE is associated with pleuritic chest pain, SOB, cough, and hemoptysis. CXR may have septic cough, and hemoptysis. CXR may have septic pulmonary emboli.pulmonary emboli.

IVDU is a risk factor for recurrent NVEIVDU is a risk factor for recurrent NVE

HIV, 27 to 73% of IVDU with IE, risk and mortality HIV, 27 to 73% of IVDU with IE, risk and mortality is inversely related to CD4 counts.is inversely related to CD4 counts.



Patient PopulationsPatient Populations Prosthetic Valve Endocarditis (PVE)Prosthetic Valve Endocarditis (PVE)

10 to 30% of all IE in developed countries10 to 30% of all IE in developed countries

““Early” PVE, symptoms within 60 days, occurs at Early” PVE, symptoms within 60 days, occurs at greater frequency than “late”greater frequency than “late”

0-12 months, PVE in mechanical > bioprosthetic0-12 months, PVE in mechanical > bioprosthetic

>12 months, PVE bioprosthetic > mechanical>12 months, PVE bioprosthetic > mechanical

By 5 years, PVE bioprosthetic = mechanical By 5 years, PVE bioprosthetic = mechanical



Patient PopulationsPatient Populations Health care-associatedHealth care-associated

Nosocomial and community-acquired as a Nosocomial and community-acquired as a consequence of indwelling devicesconsequence of indwelling devices

HD is independently associated with HD is independently associated with S. aureusS. aureus. .

Catheter-associated Catheter-associated S. aureusS. aureus bacteremia is the bacteremia is the predominant risk factor for IE in this group.predominant risk factor for IE in this group.

Treat as presumed IE, if persistent fever or Treat as presumed IE, if persistent fever or bacteremia for 4 days after catheter removed.bacteremia for 4 days after catheter removed.


Distribution of Types of IEDistribution of Types of IE

Isolated AV IE is observed in 55-60% of cases.Isolated AV IE is observed in 55-60% of cases.

Isolated MV IE occurs in 25-30% of cases.Isolated MV IE occurs in 25-30% of cases.

IE of both valves occurs in 15% of cases.IE of both valves occurs in 15% of cases.

Prosthetic valve IE constitutes 10-25% of all cases of IE.Prosthetic valve IE constitutes 10-25% of all cases of IE. Prosthetic valve IE is more common with prosthetic AV, multiple Prosthetic valve IE is more common with prosthetic AV, multiple

valves, and after replacement of an infected native valvevalves, and after replacement of an infected native valve

Roldan CA. The Ultimate Echo Guide

Distribution of Types of IEDistribution of Types of IE

Right-sided IE constitutes 5-10% of all cases.Right-sided IE constitutes 5-10% of all cases. 80% TV is involved80% TV is involved Most commonly associated with IVDUMost commonly associated with IVDU Also occurs in patients with right heart wires or Also occurs in patients with right heart wires or

catheters.catheters.

What is the incidence of culture-negative What is the incidence of culture-negative endocarditis?endocarditis? 5-10%5-10%


MicroorganismsMicroorganisms

NEJM 345 (18), 2001


What is the most common organism associated with What is the most common organism associated with endocarditis?endocarditis?

Streptococcus viridansStreptococcus viridans

What organisms are most frequently implicated in What organisms are most frequently implicated in endocarditis of IVDU?endocarditis of IVDU?

Gram negative, fungal and S. AureusGram negative, fungal and S. Aureus

Fungi cause what percentage of PVE?Fungi cause what percentage of PVE? 15%15%

What is the most frequent organism reported with What is the most frequent organism reported with myocardial abscess?myocardial abscess?

S. AureusS. AureusZevitz, M. Pearls of Wisdom Board Review


History of contact with mammals and/or birds History of contact with mammals and/or birds may suggest infection by what organisms?may suggest infection by what organisms? Coxiella burnetiiCoxiella burnetii (Q fever), (Q fever), BrucellaBrucella species or species or

Chlamydia psittaciChlamydia psittaci

A nosocomial cluster of cases postoperatively A nosocomial cluster of cases postoperatively may be caused by what organisms?may be caused by what organisms? LegionellaLegionella or or MycobacteriumMycobacterium species species

What organism, once accounted for 25% of What organism, once accounted for 25% of cases, now only 1-2% of cases?cases, now only 1-2% of cases? Neisseria gonorrhoeaeNeisseria gonorrhoeae


PathophysiologyPathophysiologyIt is hypothesized that platelet-fibrin deposition occurs It is hypothesized that platelet-fibrin deposition occurs spontaneously on abnormal valves and at sites of cardiac spontaneously on abnormal valves and at sites of cardiac endothelium injury or inflammation and that these deposits are endothelium injury or inflammation and that these deposits are called nonbacterial thrombotic endocarditis (NBTE). called nonbacterial thrombotic endocarditis (NBTE).

NBTE are the sites at which microorganisms adhere during NBTE are the sites at which microorganisms adhere during bacteremia to initiate IE. bacteremia to initiate IE.

2 mechanisms in the formation of NBTE: 2 mechanisms in the formation of NBTE: Endothelial injuryEndothelial injury Hypercoagulable state. Hypercoagulable state.

3 hemodynamic circumstances that may initiating NBTE: 3 hemodynamic circumstances that may initiating NBTE: (1) a high-velocity jet striking endothelium; (2) flow from a high- to a low-(1) a high-velocity jet striking endothelium; (2) flow from a high- to a low-

pressure chamber; and (3) flow across a narrow orifice at high velocity. pressure chamber; and (3) flow across a narrow orifice at high velocity.


PathophysiologyPathophysiologyBacteremia converts NBTE to IE.Bacteremia converts NBTE to IE.

Bacteremia rates are highest for trauma of Bacteremia rates are highest for trauma of the oral mucosa (especially gingiva), than the oral mucosa (especially gingiva), than GU, and GI tract.GU, and GI tract.



Destructive effects of intracardiac infectionDestructive effects of intracardiac infection

Embolization of septic fragments of vegetations Embolization of septic fragments of vegetations to distant sites causing infarction/infectionto distant sites causing infarction/infection

Hematogenous seeding of remote sitesHematogenous seeding of remote sites

An antibody response with subsequent tissue An antibody response with subsequent tissue injury caused by deposition of preformed injury caused by deposition of preformed immune complexes or antibody-complement immune complexes or antibody-complement interaction with antigens deposited in tissues. interaction with antigens deposited in tissues.


SymptomsSymptoms % of Pts% of Pts SignsSigns % of Pts% of Pts

FeverFever 80-8580-85 FeverFever 80-9080-90

ChillsChills 42-7542-75 MurmurMurmur 80-9580-95

SweatsSweats 2525 Changing MChanging M 10-4010-40

AnorexiaAnorexia 25-5525-55 Neuro abnNeuro abn 30-4030-40

Wt lossWt loss 25-3525-35 EmboliEmboli 20-4020-40

MalaiseMalaise 25-4025-40 SplenomegSplenomeg 15-5015-50

DyspneaDyspnea 20-4020-40 ClubbingClubbing 10-2010-20

CoughCough 2525 Peripheral manifestationsPeripheral manifestations

StrokeStroke 13-2013-20 Osler nodesOsler nodes 7-107-10

H/AH/A 15-4015-40 SplintersSplinters 5-155-15

N/VN/V 15-4015-40 PetechiaePetechiae 10-4010-40

Myalgia/Arthral.Myalgia/Arthral. 15-3015-30 Janeway lesionJaneway lesion 6-106-10

Chest painChest pain 8-358-35 Roth spotsRoth spots 4-104-10



What signs and symptoms are associated with a What signs and symptoms are associated with a myocardial abscess?myocardial abscess? Low-grade fevers, chills, leukocytosis, conduction Low-grade fevers, chills, leukocytosis, conduction

system abnormalities, nonspecific ECG changes and system abnormalities, nonspecific ECG changes and sign/sx of acute MIsign/sx of acute MI

Osler’s nodes are usually nodular and painful.Osler’s nodes are usually nodular and painful. TrueTrue

What other conditions are associated with What other conditions are associated with Osler’s nodes?Osler’s nodes? NBTE, gonococcal infection and hemolytic anemiaNBTE, gonococcal infection and hemolytic anemia


Diagnosis: Duke’s CriteriaDiagnosis: Duke’s Criteria

AHA/ACC Valve Guidelines 2006

DiagnosisDiagnosis

TTE sensitivityTTE sensitivity Vegetation <5mm 25% Vegetation <5mm 25% Between 6-10mm 70%Between 6-10mm 70%

TEE sensitivity 90-100%TEE sensitivity 90-100%

Prosthetic endocarditisProsthetic endocarditis TEE >> TTETEE >> TTE

Evangelista Heart 90: 614-617 (2004)

DiagnosisDiagnosis

Class I Indications for Echocardiography in IE of Class I Indications for Echocardiography in IE of Native and Prosthetic Valves:Native and Prosthetic Valves: Detection and characterization of valvular lesions, Detection and characterization of valvular lesions,

hemodynamic severity, and ventricular compensationhemodynamic severity, and ventricular compensation Detection of vegetations and characterization of Detection of vegetations and characterization of

lesions in patients with CHDlesions in patients with CHD Detection of abscess, perforation or fistulasDetection of abscess, perforation or fistulas Reevaluation studies in patients with complex Reevaluation studies in patients with complex

endocarditisendocarditis In patients with highly suspected culture-negative IEIn patients with highly suspected culture-negative IE Evaluation of bacteremia without a known source in a Evaluation of bacteremia without a known source in a

patient with a prosthetic valve.patient with a prosthetic valve.


DiagnosisDiagnosis

Positive Echo findings:Positive Echo findings: Presence of vegetations defined as Presence of vegetations defined as mobilemobile

echodense masses implanted in a valve or mural echodense masses implanted in a valve or mural endocardium in the trajectory of the regurgitant jet or endocardium in the trajectory of the regurgitant jet or implanted in prosthetic material with no alternative implanted in prosthetic material with no alternative anatomical explanationanatomical explanation

Presence of abscess defined as definite Presence of abscess defined as definite region of region of reduced echo density, or echolucent cavitiesreduced echo density, or echolucent cavities within within annulus or adjacent myocardial structuresannulus or adjacent myocardial structures

New New dehiscencedehiscence of valvular prosthesis of valvular prosthesis



BMJ Vol. 333, Aug. 2006

Detection of ComplicationsDetection of Complications

Valve perforationValve perforation

Valvular, annular, or aortic root, or Valvular, annular, or aortic root, or myocardial abscessmyocardial abscess

Valve psuedoaneurysmValve psuedoaneurysm

FistulasFistulas

Ring dehiscenceRing dehiscence

Valvular regurgitationValvular regurgitation

PVE commonly extends beyond the valve ring into the annulus which can cause dehiscence, paravalvular

regurgitation and conduction disturbances.



BMJ Vol. 333, Aug. 2006

Subaortic Complications of Subaortic Complications of AV EndocarditisAV Endocarditis

““TEE Recognition of Subaortic Complicatons in AV TEE Recognition of Subaortic Complicatons in AV endocarditis”endocarditis”

Karalis DG, et al. (Karalis DG, et al. (CirculationCirculation 1992; 86: 353 – 362). 1992; 86: 353 – 362).

May 1988 – August 1991, 55 consecutive patientsMay 1988 – August 1991, 55 consecutive patients

44% (N = 24) had subaortic complications.44% (N = 24) had subaortic complications.Secondary involvement of the mitral-aortic intervalvular fibrosa Secondary involvement of the mitral-aortic intervalvular fibrosa (MAIVF) and the anterior mitral leaflet (AML)(MAIVF) and the anterior mitral leaflet (AML)

Direct extension of infection and/or less commonly the infected AI Direct extension of infection and/or less commonly the infected AI jet striking the subaortic structuresjet striking the subaortic structures

Abscess, aneurysm, perforationAbscess, aneurysm, perforation


Secondary infections of the subaortic structures Secondary infections of the subaortic structures may be more common than appreciated.may be more common than appreciated.

The MAIVF and AML should be investigated in The MAIVF and AML should be investigated in all patients with AV endocarditis.all patients with AV endocarditis.

Thickening of the posterior aortic root or AML Thickening of the posterior aortic root or AML with an eccentric MR color jet should alert to with an eccentric MR color jet should alert to possible subaortic complications.possible subaortic complications.

Differential Diagnosis of IEDifferential Diagnosis of IE

Valve excrescencesValve excrescences

Ruptured chordae tendineaRuptured chordae tendinea

Torn bioprosthetic leafletTorn bioprosthetic leaflet

Libman-Sacks endocarditisLibman-Sacks endocarditis

Rheumatic valvulitisRheumatic valvulitis

NBTENBTE

Papillary fibroelastomaPapillary fibroelastoma

Libman-Sacks Endocarditis

Rheumatic Valvulitis

Google Images

Papillary Fibroelastoma

Google Images

Ruptured chordae tendinea

Medical TherapyMedical Therapy

NEJM 345 (18), 2001

Indications for Valve SurgeryIndications for Valve Surgery

Endocarditis-related valvular heart failure (mortality 56 – Endocarditis-related valvular heart failure (mortality 56 – 86%)86%)

Moderate to severe CHF (NYHA III or IV)Moderate to severe CHF (NYHA III or IV)

No control of infection, difficult-to-treat microbesNo control of infection, difficult-to-treat microbesEmbolic risk (vegetation length > 15mm strong predictor Embolic risk (vegetation length > 15mm strong predictor of new EE and mortality)of new EE and mortality)Neurologic complicationsNeurologic complicationsPerivalvular infection/abscessPerivalvular infection/abscessValvular obstructionValvular obstructionUnstable prosthesisUnstable prosthesisProsthetic infective endocarditis (esp. Prosthetic infective endocarditis (esp. S. AureusS. Aureus))Fungal infective endocarditisFungal infective endocarditis

Circulation 2005; 112: 69-75

JACC 2001; 37: 1069

Prevention/GuidelinesPrevention/Guidelines

Wilson, et al. Circulation. 2007; 115

RationaleRationale

IE prophylaxis regimen has been evolving for the IE prophylaxis regimen has been evolving for the past 50 years.past 50 years.

Basis for recommendations and quality of Basis for recommendations and quality of evidence limited to expert opinion, small trails evidence limited to expert opinion, small trails [Class IIb, LOE C][Class IIb, LOE C]

Several assumptions have led to development of Several assumptions have led to development of abx prophylaxis in humans, and these abx prophylaxis in humans, and these assumptions have been recently questionedassumptions have been recently questioned


RationaleRationale

AHA/ACC guidelines have become overly AHA/ACC guidelines have become overly complicated and wrought with ambiguities, complicated and wrought with ambiguities, making interpretation difficult for practitioners.making interpretation difficult for practitioners.

Potential consequences of changes include: Potential consequences of changes include: altering established practice, decreasing pts altering established practice, decreasing pts eligible for prophylaxis, decreasing malpractice eligible for prophylaxis, decreasing malpractice suits and spurring more trialssuits and spurring more trials


EvidenceEvidence

(1) Frequency, nature, magnitude, and duration of (1) Frequency, nature, magnitude, and duration of bacteremia associated with dental proceduresbacteremia associated with dental procedures

(2) Impact of dental disease, oral hygiene, and type of (2) Impact of dental disease, oral hygiene, and type of dental procedure on bacteremiadental procedure on bacteremia

(3) Impact of antibiotic prophylaxis on bacteremia from a (3) Impact of antibiotic prophylaxis on bacteremia from a dental procedure dental procedure

(4) The exposure over time of frequently occurring (4) The exposure over time of frequently occurring bacteremia from routine daily activities compared with bacteremia from routine daily activities compared with bacteremia from various dental procedures.bacteremia from various dental procedures.


EvidenceEvidence

Dental proceduresDental procedures Transient bacteremia is common with manipulation of Transient bacteremia is common with manipulation of

the teeth and periodontal tissues.the teeth and periodontal tissues.

Wide variation in reported frequencies of bacteremia Wide variation in reported frequencies of bacteremia in patients resulting from dental procedures:in patients resulting from dental procedures:

Tooth extraction (10% to 100%), Tooth extraction (10% to 100%),

Periodontal surgery (36% to 88%), Periodontal surgery (36% to 88%),

Teeth cleaning (up to 40%)Teeth cleaning (up to 40%)

Endodontic procedures (up to 20%)Endodontic procedures (up to 20%)


EvidenceEvidence

Routine daily activities Routine daily activities Unrelated to a dental procedureUnrelated to a dental procedure

Tooth brushing and flossing (20% to 68%) Tooth brushing and flossing (20% to 68%)

Use of wooden toothpicks (20% to 40%)Use of wooden toothpicks (20% to 40%)

Use of water irrigation devices (7% to 50%)Use of water irrigation devices (7% to 50%)

Chewing food (7% to 51%)Chewing food (7% to 51%)


EvidenceEvidence

Few published studies exist on the magnitude of Few published studies exist on the magnitude of bacteremia after a dental procedure or from bacteremia after a dental procedure or from routine daily activities, and most of the published routine daily activities, and most of the published data used older, often unreliable microbiological data used older, often unreliable microbiological methodology. methodology.

There are no published data that demonstrate There are no published data that demonstrate that a greater magnitude of bacteremia, that a greater magnitude of bacteremia, compared with a lower magnitude, is more likely compared with a lower magnitude, is more likely to cause IE in humans.to cause IE in humans.


EvidenceEvidence

The magnitude of bacteremia resulting from a The magnitude of bacteremia resulting from a dental procedure is relatively low, similar to that dental procedure is relatively low, similar to that resulting from routine daily activities, and is less resulting from routine daily activities, and is less than that used to cause experimental IE in than that used to cause experimental IE in animal.animal.

Although the infective dose required to cause IE Although the infective dose required to cause IE in humans is unknown, the number of in humans is unknown, the number of microorganisms present in blood after a dental microorganisms present in blood after a dental procedure or associated with daily activities is procedure or associated with daily activities is low.low.


Dental RecommendationsDental Recommendations

The vast majority of cases of IE caused by oral microflora most The vast majority of cases of IE caused by oral microflora most likely result from random bacteremias caused by routine daily likely result from random bacteremias caused by routine daily activities, such as chewing food, tooth brushing, flossing, use of activities, such as chewing food, tooth brushing, flossing, use of toothpicks, use of water irrigation devices, and other activities. The toothpicks, use of water irrigation devices, and other activities. The presence of dental disease may increase the risk of bacteremia presence of dental disease may increase the risk of bacteremia associated with these routine activities.associated with these routine activities.

There should be a shift in emphasis away from a focus on a dental There should be a shift in emphasis away from a focus on a dental procedure and antibiotic prophylaxis toward a greater emphasis on procedure and antibiotic prophylaxis toward a greater emphasis on improved access to dental care and oral health in patients with improved access to dental care and oral health in patients with underlying cardiac conditions associated with the highest risk of underlying cardiac conditions associated with the highest risk of adverse outcome from IE and those conditions that predispose to adverse outcome from IE and those conditions that predispose to the acquisition of IEthe acquisition of IE


GI/GU RecomendationsGI/GU Recomendations

The possible association between GI or GU tract The possible association between GI or GU tract procedures and IE has not been studied as procedures and IE has not been studied as extensively as the possible association with extensively as the possible association with dental procedures.dental procedures.

The administration of prophylactic antibiotics The administration of prophylactic antibiotics solely to prevent endocarditis is not solely to prevent endocarditis is not recommended for patients who undergo GI or recommended for patients who undergo GI or GU procedures, including EGD or colonoscopy.GU procedures, including EGD or colonoscopy.


Summary of Major ChangesSummary of Major Changes


Highest Risk PatientsHighest Risk Patients


RegimansRegimans


Bacterial PericarditisBacterial Pericarditis

Bacterial pericarditis is not synonymous with Bacterial pericarditis is not synonymous with purulent pericarditis.purulent pericarditis.

50% have classic signs: chest pain, rub, pulsus 50% have classic signs: chest pain, rub, pulsus

Staph and strep are the most common Staph and strep are the most common organisms, 22-31%organisms, 22-31%

Sources:Sources: Lung 40%, hematogenous 22-29%, trauma 24-29%, Lung 40%, hematogenous 22-29%, trauma 24-29%,

endocarditis/abscess 14-22%endocarditis/abscess 14-22%

Pankuweit S et al. Bacterial Pericarditis, Diagnosis and Management. Am J Cardiovasc Drugs 2005; 5(2): 103-112.


Purulent pericarditis is fatal if untreated, 40% mortality.Purulent pericarditis is fatal if untreated, 40% mortality.

TB Pericarditis:TB Pericarditis: Effusive-contrictive (30-50%)Effusive-contrictive (30-50%) 85% mortality if left untreated.85% mortality if left untreated. Pericardial biopsy is more sensitive than pericardiocentesis Pericardial biopsy is more sensitive than pericardiocentesis

(100% vs 33%)(100% vs 33%)

AIDS Pericarditis:AIDS Pericarditis: Leading cause of infectious pericarditisLeading cause of infectious pericarditis 35% MAI35% MAI



Management:Management: First emperic antibiotic therapy (anti-staph First emperic antibiotic therapy (anti-staph

and aminoglycoside), then tailor therapy.and aminoglycoside), then tailor therapy. Open surgical drainage is preferred.Open surgical drainage is preferred. Rinsing pericardium with antibiotics, Rinsing pericardium with antibiotics,

urokinase/ streptokinase may help clear urokinase/ streptokinase may help clear infection.infection.

Pericardiotomy is recommended for recurrent Pericardiotomy is recommended for recurrent effusions.effusions.


Echo Findings of ConstrictionEcho Findings of Constriction

1) Increased pericardial thickness and 1) Increased pericardial thickness and occasionally calcificationoccasionally calcification TEE measurement correlates with CTTEE measurement correlates with CT

2) Septal shudder/bounce2) Septal shudder/bounce3) RV/LV inflow – increased E velocity3) RV/LV inflow – increased E velocity Due to early rapid diastolic fillingDue to early rapid diastolic filling

4) Tissue doppler – prominent E velocity4) Tissue doppler – prominent E velocity Major difference between constriction and restrictionMajor difference between constriction and restriction

5) Other: IV/hepatic v. dilation, biatrial 5) Other: IV/hepatic v. dilation, biatrial enlargementenlargement


Echo Findings of ConstrictionEcho Findings of Constriction

UptoDate: Hemodynamics of Constrictive Pericarditis vs Restrictive Cardiomyopathy

Device InfectionsDevice Infections

The Prospective Evaluation of Pacemaker Lead The Prospective Evaluation of Pacemaker Lead Endocarditis study is a multicenter, prospective survey of Endocarditis study is a multicenter, prospective survey of the incidence and risk factors of infectious complications the incidence and risk factors of infectious complications after implantation of pacemakers and cardioverter-after implantation of pacemakers and cardioverter-defibrillators. defibrillators.

January 1 - December 31, 2000, 6319 consecutive January 1 - December 31, 2000, 6319 consecutive recipients of implantable systems were enrolled at 44 recipients of implantable systems were enrolled at 44 medical centers and followed up for 12 months. medical centers and followed up for 12 months.

Infections developed over 12 months in 42 patients, Infections developed over 12 months in 42 patients, incidence of 0.68/100 patients.incidence of 0.68/100 patients.

Circulation, Sept. 2007, 116: 1349-1355

ConclusionsConclusions

The epidemiology of IE has changed in developed The epidemiology of IE has changed in developed countries.countries.

TEE has a 95% sensitivity in detecting vegetations and is TEE has a 95% sensitivity in detecting vegetations and is also key in finding complications of vegetations.also key in finding complications of vegetations.

Moderate to severe heart failure and vegetation length Moderate to severe heart failure and vegetation length are important indications for surgery.are important indications for surgery.

Antibiotic prophylaxis regiman for IE was updated in Antibiotic prophylaxis regiman for IE was updated in 2007. 2007.

Questions/Comments??Questions/Comments??

endocarditis & infections of the heart

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