ISKANDER AL-GITHMI, MD, FRCSC Consultant Cardiothoracic Surgeon Assistant Professor of Surgery King Abdulaziz University ISKANDER AL-GITHMI, MD, FRCSC Consultant Cardiothoracic Surgeon Assistant Professor of Surgery King Abdulaziz University “CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS”

It is of use, from time to time, to take stock, so to speak of our knowledge of a particular disease, to see exactly where we stand in regards to it, to inquire to what conclusion the accumulated facts seem to point and to ascertain in what direction we may look for fruitful investigation in the future….I propose to do this in the case of that most interesting disease known as ulcerative endocarditis. “Endocarditis Milestones” Clinical syndrome; described by Sir William Osler. CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS

Penicillin (Alexander Fleming) Von Reyn Criteria [Persistant bacteremia, New regurgitant murmur and vascular Complications] Duke’s Criteria proposed by Dr. Durack from Duke University. CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS

“Background” Despite improvement in health care and advancement in diagnostic technology and therapy; the incidence of infective endocarditis has not decreased over the past decades. Progressive evolution in risk factors: - i.e. i.v. drug use - Use of prosthetic valve - Growing resistant micro-organisms. Incidence of Infective endocarditis ~ to 20,000 new cases per year. CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS

Infective endocarditis classifications: Native – valve endocarditis: associated with congenital heart disease and chronic rheumatic heart disease. Prosthetic-valve endocarditis: 1-5% of individual with infective endocarditis have PVE Early-PVE: infection within 60 days of surgery Late -PVE: infection 2-6 months of surgery CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS

Infective endocarditis in intravenous drug user - Common in young population - Tricuspid valve involved in up to 50% of cases - Predominant pathogenes usually staph aureus Important iatrogenic risk factors for infective endocarditis - hemodialysis - 3 times more frequent than in general population - Predominant pathogenes is staph aureus. CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS

“Pathogenesis” Bacterial adherence to damaged valve: - Mechanical lesions - Inflammatory lesions CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS

“Diagnosis Pre-requisite” High index of suspicious Early TEE: High sensitivity 75-95% Specificity 85-98% CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS

Duke Clinical Criteria CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS

“Management Strategies” It is multi-disciplinary and team work - Cardiologist - Echo Cardiologist - Cardiac Surgeon - Infectious Disease - Neurologist CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS

“Echocardiography in infective endocarditis” Extremely important not only to make diagnosis but for early detection of potential complications. CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS

Major Complications - Thrombo-embolism - Heart Failure - Peri-annular extension of infection and annular dehiscence CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS

Thrombo-embolism Rate 50% Major 30 – 40% Sub-clinical 10-20% Up to 65% of embolic event involve CNS 90% of CNS embolism lodge in the distribution of middle cerebral artery. More than 90% of embolization developed within the 1 st 3 weeks of the diagnosis of infective endocarditis The rate of embolization decreased overtime during anti- microbial therapy. CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS

Results of Previous Studies

Echocardiography predicts embolic events in infective endocarditis. Study design: Prospective Patients: 178 Consecutive patients with definite diagnosis of infective endocarditis All had multi-plane TEE CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS

Results of Univariate and Multiple Stepwise Logistic Regression Analyses

CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS

“Clinical Implications of the Study” The presence of vegetation visualized by echocardiogram is a predictive of embolism The morphological characteristic of vegetations are very helpful in predicting the embolic events. CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS

“What is the time interval required for surgical intervention in infective endocarditis?” CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS

Presence of vegetations is a strong indication for surgical intervention, irrespective of valve destruction, heart failure or response to anti- microbial therapy. Embolic events is extremely high in the early stage of the disease. Embolic events can occur up to 20% of cases from vegetation less than 10mm. CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS

“Congestive Heart Failure (CHF)” CHF may develop insidiously, despite appropriate antibiotics as a result of progressive valvular insufficiency and ventricular dysfunction. CHF in infective endocarditis; portends a grave prognosis with medical therapy. Delaying surgery to the point of ventricular decompensation dramatically increase operative mortality from 6% to 11% for patient without CHF, 17-33% for patient with CHF. CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS

Periannular extension of infection and annular dehiscence - Extension of infective endocarditis beyond the valve annulus predict higher mortality, more frequent development of CHF and the need for surgical intervention. - It occurs in 10-40% of all native-valve endocarditis and 56% to 100% in PVE. CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS

“Management Approach to Infective Endocarditis” Surgical versus medical therapy in active complicated native valve infective endocarditis. CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS

Indications for Surgery (Group A) and Criteria for Inclusion in Group B

CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS Site of Involvement by Endocarditis

CHALLENGING ISSUES IN INFECTIVE ENDOCARDITIS

“Conclusions” Despite improvement in healthcare and major advance in the diagnostic technology as well as medical-surgical therapies, endocarditis has not decreased but new risk factors have evolved. Treatment of this infection require a multidisciplinary approach. Early surgery is critically important and maybe the only best option in patients with infective endocarditis irrespective of heart failure, valve destruction and response to antimicrobial therapy. New clinical research studies should be used to provide definite answers to several remaining questions about this complex infection.