apport des - endocardites aquitaine · apport des recommandations européennes gilbert habib...

Apport des

recommandations européennes

Gilbert HabibCardiology Department- La Timone Marseille - France

Bordeaux le 28 Juin 2011

Infective Endocarditis: a changing disease

new high-risk subgroups

changing microbiology

IVDAelderlyintracardiac devicesnosocomial diseases

changing microbiology

increasing incidence of staphylococcal IEnew microorganisms (Coxiella burnetii, Bartonella spp, Tropheryma whipplei)

more difficult to prevent

more difficult to diagnose

more difficult to treat

IE: new guidelines ESC 2009

1. prevention

2. diagnosis

3. treatment

Case report 1

Incidence des bactériémies quotidiennes

Duval X, Leport C. Lancet Infect Dis 2008 ; 8 : 225-32

Adapted from Moreillon Med Mal Infect 2002 ; 32 : 605-12

Strain : MRSA P8

Inoculum: 1.6 -2.0x10 3 CFU/rat

60

80

100ve

geta

tions

Strain : MRSA P8

Inoculum: 1.6 -2.0x10 3 CFU/rat

60

80

100ve

geta

tions

Experimental Endocarditis Revisited

Bolus(1 ml/1 min)

Continuous inf.(0.1ml/h/10h)

0

20

40

60

Type of Inoculum

% o

fin

fect

edve

geta

tions

n= 9

Bolus(1 ml/1 min)

Continuous inf.(0.1ml/h/10h)

0

20

40

60

Type of Inoculum

% o

fin

fect

edve

geta

tions

Entenza et al, in press

n= 9n= 9

PMo PMo –– UNI LausanneUNI Lausanne

Preexisting disease and risk of IE

High risk Moderate risk Low risk

Acquired valve dysfunction

Hypertrophic cardiomyopathy

MVP with regurgitation and/or

thickened valves

Isolated ASD

Surgical repaired ASD, VSD, PDA

Previous CABG surgery

MVP without MR

Prosthetic heart valves

Previous IE

Congenital heart disease

Bicuspid aortic valve Innocent heart murmurs

Previous Kawasaki disease

Pacemakers / defibrillators

ESC Guidelines Infective Endocarditis 2004




thickened valves

Isolated ASD



MVP without MR


Previous IE







Prophylaxis recommended (I C)



Previous IE





thickened valves

Isolated ASD



MVP without MR






Prophylaxis recommended (IIa C)


Cardiac conditions at highest risk of IE

Procedures at highest risk of IE

IE prevention: main changes

1. The principle of antibiotic prophylaxis when performing procedures at risk

of IE in patients with predisposing cardiac conditions is maintained , but

2. Antibiotic prophylaxis must be limited to patients with the highest risk of

IE undergoing the highest risk dental procedures.

3. Good oral hygiene and regular dental review are more important than

antibiotic prophylaxis to reduce the risk of IE. antibiotic prophylaxis to reduce the risk of IE.

4. Aseptic measures are mandatory during venous catheter manipulation and

during any invasive procedures in order to reduce the rate of health care-

associated IE.

5. Whether the reduced use of prophylaxis is associated with a change in the

incidence of IE must be evaluated by prospective studies

Reco ESC 2010

Une bonne hygiène dentaire et un suivi dentaire régulier sont recommandés chez les patients à risque

Le piercing et les tatouages doivent être évités chez ces patients, surtout les piercings intéressant les muqueuses.patients, surtout les piercings intéressant les muqueuses.

Des mesures d’asepsie rigoureuse sont recommandées lors de la manipulation des cathéters ou durant toute procédure invasive, afin d’éviter les endocardites nosocomiales

1. simplification

2. réduction

CONCLUSIONS: LES ENJEUX

3. uniformisation

4. évaluation


1. prevention

2. diagnosis

3. treatment

Case report 2

75 year-old woman, 2008: aortic bioprosthesis for aortic stenosis atrial flutter 2010december 2010: unexplained fever

History of the disease

Case report 2

no sign of CHFfever = 38°5aortic systolic murmur 2/6arterial pressure: 140 / 70 mmHgnormal neurological examination

Clinical examination

haemoglobin: 11 g / dlwhite blood cell count: 9,400 / mm3

sedimentation rate: 40 mmCRP = 35 mg/lcreatinin = 69 mg

Laboratory data

Case report

creatinin = 69 mg

Blood cultures / serologies:

negative

TEETEE

new episodes of unexplained fever

April 2011

no sign of CHFfever = 37°aortic systolic murmur 2/6


4 months later

haemoglobin: 10 g / dlwhite blood cell count: 8,400 / mm3

sedimentation rate: 40 mmCRP = 12 mg/l

Laboratory data

negative

Blood cultures

TEETEE

TEETEE

April 8, 2011December 20, 2010

DecisionDecision

1. Consider infective endocarditis (BCNIE)

2. Initiate antibiotic therapy

Vancomycin: 6 weeksVancomycin: 6 weeks

Gentamycin: 2 weeks

3. Close follow-up, perform:

repeat TTE / TEE

TEP scan

PET scan PET scan

FollowFollow--up up underunder therapytherapy

no fever

normal sedimentation rate, CRP, white blood cells

TTE: normally functioning bioprosthesis

blood cultures: negative

TEETEE

TEETEE

April 8, 2011 April 21, 2011

SurgerySurgery performedperformed on April 29, 2011on April 29, 2011

thickened aortic leaflets

small aortic vegetation

resection of infected tissues

bioprosthetic valve replacement

Surgical findings Surgical approach

posterior aortic root abscess

bioprosthetic valve replacement

Valve cultures

negative

SurgerySurgery performedperformed on April 29, 2011on April 29, 2011

PCR of the valve

identification of Bartonella henselae spp

Doxycycline 200 mg/d

The Duke echographic criteria Durack DT Am J Med 1994 ; 96 : 200-9

vegetation abscess new dehiscence

of prosthetic valve

*TEE is not mandatory in isolated right-sided native valve IE with good quality

TTE examination and unequivocal echocardiographic findings.

Diagnostic value of 3D echo

Aortic bioprosthetic abscess

October 6, 2009September 23, 2009

Recommendation 1: diagnosis1) TTE is recommended as the first imaging modality in suspected IE

2) TEE is recommended in patients with high clinical suspicion of IE and a

normal TTE

3) TEE should be considered in the majority of patients with suspected IE, even

in case with positive TTE

4) Repeat TTE/TEE within 7-10 days is recommended in case of initially

negative examination when clinical suspicion of IE remains high

5) TEE is not indicated in patients with good-quality negative TTE

and low clinical suspicion of IE

Role of echocardiography in IE


1. prevention

2. diagnosis

3. treatment

Case report 3

52 year-old woman, march 2009 : fever and lombalgiadiagnosis of spondylitisno previous known cardiac diseasehospitalisation in the cardiology Department: June 4th, 2009

History of the disease

Case report

no sign of CHFfever = 38°5mitral systolic murmur 2/6arterial pressure: 120 / 70 mmHgnormal neurological examination


haemoglobin: 8.5 g / dlwhite blood cell count: 11,000 / mm3

sedimentation rate: 60 mmCRP = 136 mg/lcreatinin = 60 mg

Laboratory data

Case report

creatinin = 60 mg

Blood cultures:

streptococcus bovis (group D)

TEETEE

CTCT--scan scan imagingimaging

normal LV and RV function,

large (26 mm) mitral vegetation (A2)

probable A2 perforation

Patient case: summary

moderate mitral regurgitation: ERO = 28 mm²

no CHF

spondylitis, multiple emboli

1.1. Is early surgery necessary ?Is early surgery necessary ?

2.2. What is the optimal timing for surgery ?What is the optimal timing for surgery ?

60

80

100

Surgery in IE : Euro Heart Survey

Tornos P – Heart 2005 ; 91 : 571-5

Reasons for surgeryReasons for surgery

Surgery performed

Medical therapy only

0

20

40

nativen = 118

PVEn = 41

51 % 49 % CHF: 65%persistent sepsis: 45%embolism: 20%

Reasons for surgeryReasons for surgery

New guidelines 2009: native IE

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