ECHO 2013 / Clinical Decision Making Endocarditis and the Role of Echo
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Clinical Decision Making:
Endocarditis and the Role of
Echo
Carol L. Chen
April 4, 2013
State-of-the-Art Echo
New York
No financial disclosures
Infective endocarditis in the 21st Century
Murdoch, DR et al. Arch Intern Med 2009:169(5)
•In hospital mortality 15-20%
•One year mortality approaching 40%
•Acute presentation vs chronic/subacute disease
•Less rheumatic heart disease (<5%)
•Increasing age, degenerative valve disease
•North America: Increasing health care-associated infections (38%)
•Staph aureus predominant infectious agent (32%)
U.S. Guidelines
•2003 ACC/AHA/ASE Guidelines for the clinical application of echocardiography
•2005 AHA Infective Endocarditis: diagnosis, antimicrobial therapy and management of complications
•2006 ACC/AHA: Guidelines for the management of patients with valvular heart disease
•2008 ACC/AHA Guideline Update on Valvular Heart Disease: focused update on IE
2008 Change in IE prophylaxis guidelines
•Prophylaxis is not recommended solely on the basis of increased lifetime risk of acquisition of IE.
•Only an extremely small # of cases may be prevented by antibiotic prophylaxis for dental procedures
Nishimura, VHD focused update on IE. Circulation 2008.
High-risk population /at highest risk for poor outcome from IE: Endocarditis prophylaxis recommended
•Prosthetic heart valve or prosthetic repair
•Previous infective endocarditis
•Valvulopathy after cardiac transplant
•Congenital heart disease:
•Unrepaired cyanotic CHD, palliative shunts, conduits
•Completely repaired with prosthetic material (6 months)
•Repaired CHD with residual defects
Nishimura, 2008 Focused Update. Circulation 2008, 118:887-896
Other common lesions at risk for endocarditis
MVP with MR |
Aortic stenosis |
|
Rheumatic heart disease |
Bicuspid AV
Pathologic diagnosis of IE
•Fibrin-platelet thrombus on endocardial surface (degenerative valve disease, trauma, infectious agent)
•Colonized by bacteria
Clinical Diagnosis of IE: Modified Duke Criteria (2000)
Li, et al. Clin Infect Dis. 2000. 30 (4):633-638
ACC VHD Guidelines 2008/ESC 2009
Habib et al. ESC Committee for Practice Guidelines. EHJ 2009;30:2369-413
TEE indications
Bonow, et al. Guidelines on VHD. JACC 2006;48
•Class I
•TTE is nondiagnostic in patient with valvular lesions and positive blood cultures.
•To assess complications of IE, i.e. abscess/perforation/shunt.
•Prosthetic valve endocarditis is suspected
•Preoperative evaluation prior to surgery for endocarditis
•Intraoperative TEE for valvular surgery for endocarditis
•Assess valve function in endocarditis if TTE is nondiagnostic