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IE in the CCUMarwa Sayed Meshaal,MD cardiology, Kasr El-Aini
IE is one of the most serious diseases in cardiology It is associated with high in-hospital mortality, ranging from 16% -25%
Considered as the 2nd fatal infective disease
At many situations IE patients are admitted to the CCU
Heart FailureHas the greatest impact on prognosis
CHF is more frequent with AV infection then with MV or TV
Causes:Mechanical lesion : rupture chordae, perforation, valve obstruction by bulky vegetations, acute valve dehiscence, stuck valve, intracardiac fistulae Toxic myocarditis
Class I indication for urgent or sometimes emergency surgery
Slightest evidence for increased LVED pressure is serious
Management Medical management is just a bridgeCorrect any reversible predisposing factorsDon not push aggressive diuresisIV vasodilators
Ring AbscessPersistent feverDenotes intracardiac spread of infectionDiagnosisClinically: persistent fever pericardial rubECG: long PR intervalprolongation of PRwidening of QRSEchocardiography: pericardial effusion TEE is mandatory Thickening of the Ao. wall
Complications and squealaeIntracardiac fistulaeDissection into the pericardium (fatal)
ManagementClass I indication for urgent surgery
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CNS Embolization Neurologic complications, dramatically changes the prognosis & affect ttt plan
Such complications are clinically apparent in 20% -40% of cases
True incidence of acute brain embolization is not actually known
In general CNS takes up to 65% of the systemic embolization in IE
Mostly involve MCA
Can result in infarction, hge, or mycotic aneurysm
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Cerebral ischemic infarction :Stop anticoagulation in S aureus infection and with large infarctionsAt least for 2 weeksBetter only if not life threatening to postpone surgery for 2 weeksCerebral dehydrating measures if needed
Cerebral hge:Reverse anticoagulation immediatelyFollow with brain CTArrange for conventional 4vessel or cerebral CT angiographyCerebral dehydrating measuresSystolic ABP > 130 mmHgnemodipineSurgical evacuation
ICMA :ICMAs represent a relatively small, but extremely dangerous subset of this group
True incidence of ICMAs is not known
Overall mortality 60%, 80% in pt. with ruptured ICMAs & 30% in pt. with unruptured ICMAs
Most of ICMA remain silent until rupture
Treating ICMA before rupture might change prognosis among these pt.s
Distal Arterial Embolization Can result in acute limb ischemia, mycotic aneurysms, or just pulse deficit
AR can mask pulse deficit
Embolectomy might be needed
Avoid the use of anticoagulation totally
Reassess limb ischemia after cardiac surgery
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Splenic Abscess Embolization to the spleen can result in splenic infarction or abscess
Only about 5% of splenic infarctions develop abscess
One of the causes of persistent or relapsing fever or infection
US or CT guided aspiration seems to be a good choice for persistent splenic abscess
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Anticoagulation in IE Should be used only when there is definite indication
Initially stop oral anticoagulation in PVE, then shift the pt. to IV heparin infusion when INR is