Thank you to our cards team (Manoj, Noa and Nicole) for presenting the case of an elderly woman with hx of AVR presenting both native and prosthetic valve enterococcus endocarditis involving in the mitral valve and aortic valve. She is awaiting more urgent cardiac surgery given worsening MR and heart failure. A fun case where we learned a ton about endocarditis and HH nailed the organism prior to speciation!
- In a patient with a positive UA with negative nitrites one should think of gram-positive organisms including enterococcus.
- Ceftriaxone is not active alone against enterococcus, however ampicillin and ceftriaxone (CTX) are used in conjunction b/c CTX augments the activity of ampicillin.
- If you have a high concern for endocarditis send 3 sets of blood cultures prior to abx!
Approach to prosthetic valve endocarditis:
- Early (<30d): often are virulent organisms including S aureus, GNRs. Fungemia is BAD!
- Late: Similar organisms to native valve endocarditis (staph, step and enteroccus), plus fungal organisms.
Indications for TEE
- Evaluation of endocarditis after a poor/unclear TTE study or possible complications (eg, fistula, abscess)
- Evaluate for valve disorders pre or post operatively
- Evaluation for left atrial/LAA thrombus in a patient with atrial fibrillation/atrial flutter to facilitate clinical decision making regarding anticoagulation, cardioversion, or ablation
- Suspected acute aortic pathology (ie, dissection, transsection, intramural hematoma).
- Evaluation of source of embolism in a young (<50 years) patient for whom a TEE would be performed if the TTE was normal
Global Indications for Surgery in Valve Endocarditis – (see table below)
- Heart Failure
- Uncontrolled infection
- Persistent Emboli
See more info in this fantastic 2013 NEJM Infective Endocarditis review article by Hoen and Duval. Table 2 is a great summary below.
Definitions of early surgery
- There is no consensus as to the optimal timing of early surgery.
- The ESC guideline classifies surgical indications in IE as emergent (within 24 hours), urgent (within a few days), and elective (after 1-2 weeks of antibiotic therapy).
- The AHA/ACC guideline defines early surgery as occurring during the initial hospitalization and before completion of a full therapeutic course of antibiotics.
Favorite PEARL from Anne this am!
- Early intervention for endocarditis related valve dysfunction is associated with significantly reduced composite end point of death from any cause and embolic events by decreasing risk of systemic embolism. See the NEJM original article here: http://www.nejm.org/doi/full/10.1056/NEJMoa1112843
- When advocating for your patients send this to your friendly CT Surgery colleagues 🙂