PowerPoint Presentation

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

7

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

8

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

13

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

14

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