ECHO 2013 / Clinical Decision Making Endocarditis and the Role of Echo

1 week later

TEE #2 persistent fevers and (+)MRSA

Prosthetic valve endocarditis (PVE)

•10-20% of IE

•5% of prosthetic valves infected over lifetime

•Early: 60 days (coag neg staph, GNB, candida) vs late: 60+days (staph, strep, enterococci)

•TTE low sensitivity

•Reop mortality 10-17%; 5 year survival 56-82%

•Staph aureus PVE: very high risk of mortality

(>45%). (Chirouze et al. Clin Infect Dis 2004:38:1323-7)

64 yo male 60 days post bioAVR with root replacement for bicuspid aortic valve regurgitation and root dilatation.

Baseline post op (PR=184ms)

4 weeks after (PR=328ms)

PV endocarditis

•Highest risk in first 3 months after surgery, remains high through 6 months then gradually falls >1 year.

•Early PVE->nosocomial, MRSE

•Risk of IE: Mech vs Bio

•0-12 months: MV= BV

•18+ mthsBV > MV

Abscess

•Sensitivity of TTE 50%; TEE 90%

•Increased suspicion if aotic annulus >1.0cm on TTE

•More frequent in AV and prosthetic valves

•Usually involves mitral-aortic intervalvular fibrosa (MAIF)

•Echo definition: Perivalvular zone of reduced or heterogenous echo density or cavity. May be pulsatile.

• heart block, or compression of cardiac structures (coronary arteries). Progess to fistula

•Poorer prognosis

Right-sided IE

•Less common. 5-10% IE cases.

•Most frequent in IVDAs, but increasingly seen with PPM, ICD, catheters. Also with congenital heart disease.

•In hospital mortality <10%

•2 week treatment with oxacillin or rifampin/cipro possible if

•MSSA

•Single site of infection, no empyema, no complications, not immunosuppressed, <20mm veg, not prosthetic valve