Why Did This Heart Break?

Montana ACP Meeting

September 2016

Sarah H. Fenton, MD, FACC

St. Peter’s Medical Group

History

56 year old male with a known muscular VSD

3 mo dry cough, post-nasal drip

PMD and 2 Urgent Care visits

Z-Pak twice

Fever 104° 6 weeks prior to ED visit

1 month DOE

1 week orthopnea and PND

Physical Exam (1)

VS: T 98°, BP 146/51, HR 99, RR 18 mildly labored, 97%

sat on RA.

Skin: Warm and dry, no rash.

HEENT: NC/AT, conjunctiva pink, sclerae anicteric,

oropharynx clear.

Neck: 10-12 cm JVD, carotids 2+ with bilateral murmur

radiation.

Lungs: Decreased at bases with crackles.

Physical Exam (2)

Heart: PMI laterally displaced, tachycardic, regular. Normal S1, S2. Grade II-III/VI systolic murmur LSB with radiation throughout precordium, Grade I/VI early diastolic murmur aortic area without radiation. No S3 or S4. No rub.

Abdomen: Normal BS, soft, nontender. No HSM.

Extremities: No clubbing, cyanosis or edema. 2+ DP and PT pulses (waterhammer) bilaterally. Trace-1+ ankle and lower pretibial edema bilaterally.

Neurologic: Slow to respond to questions (received Ativan). No gross motor deficits.

Diagnostic Studies (1)

Labs: WBC 13.8 (84% neutrophils), Hgb 12.0, plt 406K,

K+ 4.0, BUN 13, Cr 0.93, Glucose 97, AST 25, ALT 29,

troponin .08, proBNP 5676.

ECG: ST, 1° AV block, LAE, high LV voltage. No prior.

AP CXR: Pulmonary vascular congestion, small bilateral

pleural effusions, prominent pulmonary arteries.

Diagnostic Studies (2)

Echocardiogram

Diagnosis

NYHA Class IV CHF due to severe aortic insufficiency as

a result of subacute aortic valve endocarditis

Severe AI due to perforation of aortic valve leaflet

Appears to be a bicuspid aortic valve

Possible aortic annular abscess with fistula vs. high

membranous VSD

Known distal muscular VSD

Treatment

Blood cultures x 2

Empiric antibiotics (Vancomycin and Gentamicin)

Diuresis

Transfer for aortic valve replacement

Surgical Findings and Treatment

Bicuspid aortic valve with large vegetation, perforation and severe AI

Small vegetation ventricular surface of anterior leaflet of mitral valve

Membranous and muscular VSDs

Ascending aortic aneurysm

25 mm Edwards pericardial aortic valve, debridement and repair of mitral valve, 30 mm Hemashield graft ascending aorta, Hemashield patch 1 cm perimembranous VSD

Infective Endocarditis

Epidemiology

Pathogenesis

Special Populations

Laboratory evaluation

Diagnosis

Modified Duke Criteria

Complications

Prevention

Epidemiology

Incidence 3-10/100,000 pt years

Higher incidence urban populations

>50% over age 60

6% Rheumatic heart disease (40 years ago 1/3)

38% AV, 34% MV, 8% AV and MV, 4% TV

3.5% congenital heart disease

75% of patients have structural heart disease

15-20% in-hospital mortality

1 year mortality 40%

Pathogenesis

Endothelial damage platelet–fibrin matrix deposition

bacterial colonization

Location: Greatest blood flow forces (atrial side of

MV/TV, ventricular side of AV/PV)

Microbiology

Typical

S. aureus, Viridans strep, enterococci, HACEK organisms

(Haemophilus, Actinobacillus, Cardiobacterium, Eikenella,

Kingella)

Prosthetic valve endocarditis

Within 60 days of surgery- S. epidermidis most common,

Others (S. aureus, GN bacteria, Diphtheroids, Fungi)

Late (> 1 year after surgery)- same as native

Special Populations (1)

Elderly

Lower rates of emboli, immune-mediated phenomenon,

septic complications, vegetations

More abscesses

Higher mortality

Dialysis

Intravascular access

Higher frequency bacteremia

Impaired immune system

Calcific valve disease challenge to identify vegetation

Special Populations (2)

IVDU

S. aureus

Right and left sided valves

Previous endocarditis

Recurrent endocarditis 4.5%

Prosthetic valves

25% of all IE cases

1-3% at 1 year

3-6% at 5 years

Incidence 50x higher than general population

Diagnosis (1)

Clinical

Fever >80%, malaise, weight loss

CHF

CVA

Musculoskeletal pain

Physical

Murmur >80%

Cutaneous (petechiae, splinter hemorrhages, Osler nodes, Janeway lesions)

Roth spots

Septic emboli (osteomyelitis, spleen, CVA, PE, abscess)

Clinical Manifestations of IE

Roth spot

Osler node

Janeway lesions

Splinter hemorrhages

Diagnosis (2)

Labs

Anemia

Normal or elevated WBC

Elevated ESR, CRP

Hematuria, proteinuria, pyuria, RBC casts

2 or more BCx over 1 hour, separate sites.

3 sets of BCx >6 hrs apart if subacute. If unstable, don’t

delay antibiotics!

BCx positive in 90% of IE pts

Diagnosis (3)

Echo

Vegetation- TTE 50-90% sensitivity, TEE 90-100% sensitivity

Leaflet perforation

Annular abscess

Aneurysm

Fistula

Prosthetic valve dehiscence

Complications

CHF- 32%

Periannular extension/abscess- 14%

Systemic embolization- CVA 17%, nonCVA 22%

Acute renal failure

Immune-complex glomerulonephritis

Embolic infarct

Multiorgan failure

Interstitial nephritis from antibiotics (gent, vanco)

Modified Duke Criteria

Major criteria

Microbiologic (typical organism from BCx or path)

Endocardial involvement (new valvular regurgitant lesion OR abn echo with mass, abscess, dehiscence

Minor criteria

Predisposition (prior IE, IVDU, prosthetic valve, cyanotic CHD, other turbulent cardiac lesions)

Fever > 100.4°

Vascular phenomenon (embolic event, mycotic aneurysm, Janeway lesion)

Immunolgic phenomenon (serologic markers (RF), GN, Osler, Roth)

Microbiologic findings not meeting major criteria

Definite IE: 2 major, 1 major + 3 minor, or 5 minor

Possible IE: 1 major + 1 minor, 3 minor

Rejected: alternate explanation or resolution with <4 days antibiotics

Treatment (1)

Microbiological eradication

Bactericidal drugs up to 6 weeks

Surveillance BCx after 3-4 days of IV therapy

Treatment (2)

Empiric native valve and late PV endocarditis

Combo PCNs (Unasyn or Augmentin) and Gentamycin

Vanco + Gent + Cipro if PCN intolerant

Empiric early PVE (<12 mo after surgery)

Vanco + Gent + Rifampin

Indications for Surgery

Class I

AI, MR with increased LVEDP and resultant CHF

Destructive lesion (perforation, fistula)

New heart block, valve dehiscence, abscess, relapsing PVE

Consider if persistent fever or positive BCx 5-7d after tx

Resistant organism (S. aureus, fungi)

Class II

Recurrent emboli after appropriate antibiotic tx (IIa)

Persistent vegetation after appropriate antibiotic tx (IIa)

Mobile vegetation > 10 mm (IIb)

Prevention (1)

Class IIa

Prosthetic valve (not prosthetic material for valve repair such as annuloplasty ring, neochords, Mitra-clip, Amplatzer)

Prior IE

Congenital heart disease

Unrepaired cyanotic CHD (palliative shunts and conduits)

During 6 mo after complete repair with prosthetic material or device

Repaired CHD with residual defects

Cardiac transplant with cardiac valvulopathy

Class III

Non-dental procedures (TEE, EGD, colonoscopy, cystoscopy) in absence of active infection

Prevention (2)

2007 AHA IE Update: eliminated widespread prophylaxis

No change in rate of rise of cases since update

Never a controlled, randomized study

Prophylaxis only in dental procedures involving:

Gingival tissue manipulation

Periapical region manipulation

Perforation of oral mucosa

No evidence for IE prophylaxis in GI/GU procedures absent known enterococcal infection

The End (o’carditis)

Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC Guideline for

the Management of Patients With Valvular Heart Disease: A Report of

the American College of Cardiology/American Heart Association Task

Force on Practice Guidelines. J Am Coll Cardiol. 2014;63(22):e57-

e185. doi:10.1016/j.jacc.2014.02.536.

Resources

Question (1)

A 50 year old white male presents to his internist to discuss preventive

health care and the use of herbal supplements. He underwent an

uncomplicated percutaneous closure of a secundum ASD 2 years ago. He

recalls that his doctor has been very thorough regarding health

maintenance. His only symptom is back pain, which he attributes to his

job in construction.

He is on no medications.

His physical exam reveals a blood pressure of 138/88, HR 84 and

regular, RR 12 and unlabored. His neck reveals no JVD, carotid

upstrokes are brisk and no bruits are present. Lungs are clear. Cardiac

exam reveals a regular rhythm, normal rate. There is a Grade I/VI

systolic murmur in the 2nd RICS. No S3 or S4. Abdomen is soft, non-

tender, without obvious hepatosplenomegaly. Extremities reveal no

edema or cyanosis with 2+ DP and PT pulses.

He would like to schedule a screening colonoscopy.

Which of the following do you recommend:

1) Ampicillin 2 g po 1 hour prior to colonoscopy

2) Amoxicillin 2 g po 1 hour prior to colonoscopy

3) Gentamicin 1.5 mg/kg IV 1 hour prior to colonoscopy

4) No antibiotics

5) TEE

Question (2)

Answer: 4

Rationale:

The patient has a completely repaired congenital heart defect (ASD) with

prosthetic material and he is greater than 6 months post-procedure.

Antibiotic prophylaxis for the prevention of infective endocarditis is not

indicated after 6 months from the time of a completely repaired cyanotic

congenital heart defect, including PFO or ASD. This includes both surgical

and percutaneous repair.

In addition, according to current ACC/AHA Guidelines, prophylaxis for the

prevention of infective endocarditis is not indicated for GI or GU

procedures. Only dental procedures that involve manipulation of gingival

tissue, manipulation of the periapical region, or perforation of oral mucosa

require prophylactic antibiotics.

Question (3)

Citation:

Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC Guideline for the

Management of Patients With Valvular Heart Disease: A Report of the American

College of Cardiology/American Heart Association Task Force on Practice

Guidelines. J Am Coll Cardiol. 2014;63(22):e57-e185.

doi:10.1016/j.jacc.2014.02.536.

Question (4)