cardiac misc (incl misc AHA e.g. gen valve, arrhythmia, anticoag, endocarditis incl ppx, HOCM) Flashcards
only class 1 recommendation for infxn ppx
Secondary Prevention of Rheumatic Fever
“In patients with rheumatic heart disease, secondary prevention of rheumatic fever is indicated.”
2° ppx = PCN G IM Q4W or PCN V PO BID
for whichever is longer of:
- rheumatic fever (RF) + carditis + residual valvular dz = 10y OR >40yo
- RF + carditis + NO valvular dz = 10y OR >21yo
- RF + NO carditis = 5y OR >21yo
“In pts with documented valvular heart disease, the duration of rheumatic fever prophylaxis should be ≥10 y or until the patient is 40 y of age (whichever is longer).
Lifelong prophylaxis may be recommended if the patient is at high risk of group A streptococcus exposure. Secondary rheumatic heart disease prophylaxis is required even after valve replacement.”
Which types of dental procedures may require abx ppx for endocarditis?
“dental procedures that involve:
- manipulation of gingival tissue,
- manipulation of the periapical region of teeth, or
- perforation of the oral mucosa”
Which valvular dz entities require endocarditis abx ppx for dental procedures?
involving manipulation of gingival tissue, manipulation of periapical region of teeth, or perforation of the oral mucosa
- h/o previous IE
- prosthetic valves incl TAVI & homografts Prosthetic cardiac valves, including transcatheter-implanted prostheses and homografts.
- non-valve prostheses Prosthetic material used for cardiac valve repair, such as annuloplasty rings, chords, or clips.
- un-rx cyanotic congenital dz OR rx with residual shunts or regurg at/near prothetic material Unrepaired cyanotic congenital heart disease or repaired congenital heart disease, with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or prosthetic device.
- structural regurg in transplanted heart Cardiac transplant with valve regurgitation attributable to a structurally abnormal valve.
endocarditis abx ppx PO regimens
amoxicillin 2g x1
PCN/ampicillin allergy: Keflex 2g OR azithro 500mg OR clarithro 500mg OR doxy 100mg x1
30-60min before procedure
endocarditis abx ppx non-PO regimens
- ampicillin
- Ancef/ceftrx if PCN allergy
ampicillin 2g IM/IV x1
PCN/ampicillin allergy:
Ancef OR ceftrx 1g IM/IV x1
30-60min before procedure
preferred/default endocarditis abx ppx PO regimen
amoxicillin 2g x1
30-60min before procedure
endocarditis abx ppx PO regimens with PCN/ampicillin allergy
one of:
- Keflex 2g
- azithro OR clarithro 500mg
- doxy 100mg
x1
30-60min before procedure
Do high-IE-risk pts need endocarditis abx ppx for non-dental procedures (e.g. TEE, EGD, C-scope) in the absence of active infection?
NO
(3: no benefit)
Does a dental procedure that involves manipulation of gingival tissue require endocarditis abx ppx?
YES
(2a)
Does a dental procedure that involves manipulation of the periapical region of teeth require endocarditis abx ppx?
YES
(2a)
Does a dental procedure that involves perforation of the oral mucosa require endocarditis abx ppx?
YES
(2a)
Do patients with prosthetic valves incl TAVI & homografts require endocarditis abx ppx for high-risk dental procedures?
involving manipulation of gingival tissue, manipulation of periapical region of teeth, or perforation of the oral mucosa
YES
(2a)
Prosthetic cardiac valves, including transcatheter-implanted prostheses and homografts.
Do patients with non-valve prostheses require endocarditis abx ppx for high-risk dental procedures?
involving manipulation of gingival tissue, manipulation of periapical region of teeth, or perforation of the oral mucosa
YES
(2a)
Prosthetic material used for cardiac valve repair, such as annuloplasty rings, chords, or clips.
Do patients with previous IE require endocarditis abx ppx for high-risk dental procedures?
involving manipulation of gingival tissue, manipulation of periapical region of teeth, or perforation of the oral mucosa
YES
(2a)
Do patients with un-rx cyanotic congenital dz require endocarditis abx ppx for high-risk dental procedures?
involving manipulation of gingival tissue, manipulation of periapical region of teeth, or perforation of the oral mucosa
YES
(2a)
OR rx with residual shunts or regurg at/near prothetic material
Unrepaired cyanotic congenital heart disease or repaired congenital heart disease, with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or prosthetic device.
Do patients with rxed congenital heart dz with residual shunts or regurg at/near prothetic material require endocarditis abx ppx for high-risk dental procedures?
involving manipulation of gingival tissue, manipulation of periapical region of teeth, or perforation of the oral mucosa
YES
(2a)
OR un-rx cyanotic congenital dz
Unrepaired cyanotic congenital heart disease or repaired congenital heart disease, with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or prosthetic device.
Do patients with structural regurg in a transplanted heart require endocarditis abx ppx for high-risk dental procedures?
involving manipulation of gingival tissue, manipulation of periapical region of teeth, or perforation of the oral mucosa
YES
(2a)
Cardiac transplant with valve regurgitation attributable to a structurally abnormal valve.
post-valve-intervention periodic imaging
baseline post-proc TTE + periodic interval monitoring (1)
“In asymptomatic patients with any type of valve intervention, a baseline postprocedural TTE followed by periodic monitoring with TTE is recommended, depending on type of intervention, length of time after intervention, ventricular function, and concurrent cardiac conditions.”
initial evaluation/imaging study for suspected HCM
TTE
(1)
initial evaluation for suspected HCM
EKG (1)
TTE (1)
24-48h Holter (1)
SCD risk assessment (1)
± exercise stress test (2a)
FH (1) + cascade genetic testing (1)
“exercise stress testing is reasonable to determine functional capacity and to provide prognostic information as part of initial evaluation.”
initial evaluation/non-imaging study(ies) for suspected HCM
EKG (1)
24-48h Holter (1)
± exercise stress test (2a)
“exercise stress testing is reasonable to determine functional capacity and to provide prognostic information as part of initial evaluation.”
ongoing/subsequent imaging monitoring in HCM pts
(assuming no change in clinical status)
TTE Q1-2Y
(1)
to assess myocardial hypertrophy, dynamic LVOTO, MR, & myocardial fxn
ongoing/subsequent non-imaging monitoring in HCM pts
(assuming no change in clinical status)
EKG Q1-2Y (1)
24-48h Holter (1)
ongoing/subsequent monitoring in HCM pts
(assuming no change in clinical status)
EKG Q1-2Y (1)
24-48h Holter Q1-2Y (1)
TTE Q1-2Y (1)
SCD risk assessment Q1-2Y (1)
to assess myocardial hypertrophy, dynamic LVOTO, MR, & myocardial fxn
evaluation of clinical change or new event in HCM pt
TTE
(1)
further evaluation of HCM pts with resting LVOT gradient <50mmHg
TTE with provocative maneuvers
(1)
initial screening imaging for 1° relatives of HCM pts
TTE
(1)
initial screening for 1° relatives of HCM pts
EKG (1)
TTE (1)
cascade genetic testing (1)
further evaluation of sx HCM pts with resting & provoked LVOT gradient <50mmHg
exercise TTE
(1)
for detection & quantification of dynamic LVOTO
further evaluation of asx HCM pts with resting & provoked LVOT gradient <50mmHg
exercise TTE
(2a)
imaging during surgical septal myectomy
intraop TEE
(1)
to assess MV anatomy & fxn + myectomy adequacy
f/u imaging after septal redux tx
EtOH septal ablation OR septal myectomy
TTE within 3-6mo
(1)
to evaluate procedural results
ongoing/subsequent monitoring for 1° relatives of HCM pts who are genotype-positive, phenotype-negative
serial exam, EKG, TTE:
Q1-2Y <18yo
Q3-5Y adults
+ PRN clinical change
(1)
additional/further imaging evaluation of HCM pts if TTE is inconclusive OR pre-proc planning
TEE
(2a)
“TEE can be useful if TTE is inconclusive in clinical decision-making regarding medical therapy, and in situations such as planning for myectomy, exclusion of subaortic membrane or MR 2/2 structural abnormalities of the valve apparatus, or in the assessment of feasibility of EtOH septal ablation.”
additional/further imaging evaluation of HCM pts if ECHO is inconclusive
cardiac MRI
(1)
“For patients suspected to have HCM in whom echocardiography is inconclusive, CMR imaging is indicated for diagnostic clarification.”
additional/further imaging evaluation of HCM pts if alternative dxs are suspected
cardiac MRI
(1)
“For patients with LVH in whome there is a suspicion of alternative diagnoses, including infiltrative or storage disease as well as athlete’s heart, CMR imaging is useful.”
additional/further imaging evaluation of HCM pts not otherwise high-risk or decision still uncertain for ICD
cardiac MRI
(1)
to assess for LV wall thickness, EF, LV apical aneurysm, & LGE extent
LGE = fibrosis, ≥15% of LV mass = high-risk
additional/further imaging evaluation of HCM pts if anatomic mechanism of obstruction is inconclusive on ECHO
cardiac MRI
(1)
to inform selection & planning of septal redux tx
ongoing/subsequent imaging of HCM pts for SCD risk stratification
cardiac MRI Q3-5Y
(2b)
to eval Δs in LGE, EF, morphology incl apical aneurysm or LV thickness
“for the purpose of SCD risk stratification”
additional/further imaging evaluation of HCM pts if ECHO is inconclusive & cardiac MRI is not available
cardiac CT
(2b)
evaluation of new palpitations or lightheadedness in HCM pts
>24h Holter
(1)
“extended (>24h) EKG monitoring or event recording is recommended, which should not be considered diagnostic unless pts have had symptoms while being monitored.”
evaluation of HCM pts who may be candidates for SRT but with uncertainty re: presence or severity of LVOTO on non-invasive imaging studies
cardiac cath
(1)
for invasive hemodynamic assessment
evaluation of HOCM pts who are being considered for SRT but with uncertainty re: fxnal capacity or sx status
exercise stress test
(2b)
may be reasonable
ongoing/subsequent evaluation of HCM pts in whom fxnal capacity or sx status is uncertain
exercise stress test Q2-3Y
(2b)
may be reasonable
ICD indications in HCM pts
h/o cardiac arrest, VF, sustained VT (1)
OR at least 1 of: (2a)
- h/o unexplained syncope
- FH SCD
- massive LVH (≥3cm)
- apical aneurysm
- EF<50%
OR NSVT in children (2a) / in adults (2b)
OR extensive LGE (≥15% of LV mass) on cardiac MRI (2b)
class 1 ICD indication(s) in HCM pts
h/o cardiac arrest, VF, sustained VT (1)
class 1 ICD indication(s) in HCM pts
(1)
h/o cardiac arrest, VF, sustained VT (1)
class 2a ICD indication(s) in HCM pts
at least 1 of: (2a)
- h/o unexplained syncope
- FH SCD
- massive LVH (≥3cm)
- apical aneurysm
- EF<50%
- NSVT in children (2a)
class 2a ICD indication(s) in HCM pts
(6)
at least 1 of: (2a)
- h/o unexplained syncope
- FH SCD
- massive LVH (≥3cm)
- apical aneurysm
- EF<50%
- NSVT in children (2a)
class 2b ICD indication(s) in HCM pts
NSVT in adults (2b)
OR extensive LGE (≥15% of LV mass) on cardiac MRI (2b)
class 2b ICD indication(s) in HCM pts
(2)
NSVT in adults (2b)
OR extensive LGE (≥15% of LV mass) on cardiac MRI (2b)
class 3 ICD recommendation(s) in HCM pts
(2)
without risk factors
[and/]OR for sole purpose of competitive sports participation
(3: HARM)
class 3 ICD recommendation(s) in HCM pts
without risk factors
[and/]OR for sole purpose of competitive sports participation
(3: HARM)
SCD risk factors in HCM pts
- h/o cardiac arrest, VF, sustained VT
- h/o unexplained syncope
- FH SCD
- massive LVH
- apical aneurysm
- EF<50%
- NSVT in children (2a) / in adults
- extensive LGE on cardiac MRI
SCD risk factors in HCM pts
(8)
- h/o cardiac arrest, VF, sustained VT
- h/o unexplained syncope
- FH SCD
- massive LVH
- apical aneurysm
- EF<50%
- NSVT in children (2a) / in adults
- extensive LGE on cardiac MRI
ICD type in HCM
SDM for transvenous single-chamber OR subQ (1)
with single-coil leads (1)
based on preferences, lifestyle, expected need for brady or VT pacing
versus dual-coil leads
HOCM medical mgmt
in order of preference
- β-blockers
- non-dihydropyridine Ca channel blockers (e.g. verapamil, diltiazem)
- disopyramide (in combo with #1 or #2)
“1. [In patients with HOCM and symptom attributable to LVOTO], nonvasodilating beta-blockers, titrated to effectiveness or maximally tolerated doses, are recommended. (1)”
“2. […], for whom beta-blockers are ineffective or not tolerated, substitution with non-dihydropyridine calcium channel blockers (e.g., verapamil, diltiazem) is recommended. (1)
“3. […persistent severe symptoms…] despite beta-blockers or non-dhydropyridine calcium channel blockers, either adding disopyramide in combination with 1 of the other drugs, or SRT performed at experienced centers, is recommended. (1)”
“6. For patients with HOCM and severe dyspnea at rest, hypotension, very high resting gradients (e.g., >100mmHg), as well as all children <6w old, verapamil is potentially harmful. (3: HARM)”
pressor of choice in HOCM
Neo (phenylephrine)
(1)
after failure to respond to fluids; alone or with β-blocker
cardiac drugs to avoid in HOCM
vasodilators & digoxin
(2b)
vasodil e.g. ACE-Is, ARBs, dihydropyridine calcium channel blockers
can worsen sxs 2/2 dynamic LVOTO
indications for surgical SRT in HOCM
- severe sxs despite GDMT† (1)
- sx + concomitant cardiac surgery† (1)
- NYHA II + severe & progressive pHTN OR LA enlargement with ≥1 episode sx afib OR poor fxnal capacity on treadmill exercise testing OR young with very high resting gradients (>100mmHg)‡ (2b)
- severe sxs as an alternative to escalation of medical tx† (2b)
†at experienced (primary HCM) centers
‡at comprehensive HCM centers
expected/goal
SRT in primary/comprehensive HCM centers:
30d mortality
with surgery & with EtOH
≤1% & ≤1%
expected/goal
SRT in primary/comprehensive HCM centers:
30d morbidity
with surgery & with EtOH
“adverse complications (tamponade, LAD dissection, infection, major bleeding)”
≤10% & ≤10%
expected/goal
SRT in primary/comprehensive HCM centers:
30d PPM
with surgery & with EtOH
≤5% myectomy & ≤10% ablation
expected/goal
SRT in primary/comprehensive HCM centers:
MVR ≤1y
with surgery & with ablation
≤5% & N/A
not specified for ablation
expected/goal
SRT in primary/comprehensive HCM centers:
≥mod residual MR
with surgery & with ablation
≤5% & ≤5%
expected/goal
SRT in primary/comprehensive HCM centers:
repeat proc rate
with surgery & with ablation
≤3% & ≤10%
expected/goal
SRT in primary/comprehensive HCM centers:
improvement ≥1 NYHA class
with surgery & with ablation
>90% & >90%
expected/goal
SRT in primary/comprehensive HCM centers:
rest & provoked LVOT gradient <50mmHg
with surgery & with ablation
>90% & >90%
2 main outcomes differences in EtOH septal ablation v surgical myectomy
in EtOH ablation compared to myectomy:
1. PPM rate ≥2x
2. repeat proc rate ≥3x
PPM: ≤5% v ≤10% / repeat proc: ≤3% v ≤10%
highest risk factor for complete heart block / PPM after septal myectomy for HOCM
RBBB
(which can be caused by EtOH septal ablation)
⇒10-33% risk (SESATS)
because LBB can be resected in myectomy
post-septal myectomy LVOT gradient threshold to re-resect
> 25mmHg (provoked)
recommendation re: mild- to moderate-intensity recreational exercise in HCM
YES
beneficial to improve cardioresp fitness, physical fxn, QoL, & overall health
(1)
recommendation re: moderate- to high-intensity competitive sports OR high-intensity recreational exercise in HCM
may be considered after comprehensive eval & SDM
(2b)
initial + repeated annually with an expert provider
who conveys that the risk of sudden death and ICD shocks may be increased
recommendation re: low-intensity competitive sports in HCM
is reasonable
(2a)
recommendation re: any intensity competitive sports in genotype-positive, phenotype-negative HCM
is reasonable
(2a)
class 1 recommendation(s) re: planned valve surgery in pts with afib
potential benefits & added procedural risk of concomitant arrhythmia surgery should be discussed
(1)
class 2a recommendation(s) re: planned valve surgery in pts with sx paroxysmal or persistent afib
concomitant PVI or maze
can be beneficial
(2a)
to reduce sxs & prevent recurrent arrhythmia
class 2a recommendation(s) re: planned valve surgery in pts with afib or aflutter
LAA lig/exc
is reasonable
(2a)
to reduce risk of thromboembolic events
recommendation re: postop anticoag after LA arrhythmia surgery and/or LAAL/LAAE
“LA surgical ablation of atrial arrhythmias and/or LAA lig/excision”
anticoag ≥3mo
is reasonable
(2a)
“anticoagulation therapy” NOS
Do indications for valve intervention in severe valvular dz differ before planned pregnancy?
NO
(1)
“In symptomatic women with severe VHD who are considering pregnancy, intervention before pregnancy is recommended on the basis of standard indications.”
HOWEVER, there are 3 class <1 recs that conflict with this guideline.
indication(s) for valve intervention in asx women considering pregnancy
- severe rheumatic MS with favorable morphology: PMBC @ CVC (2a)
- severe AS: “intervention” (2a)
- severe MR suitable for rx: MVRx @ CVC (2b)
indication(s) for valve intervention in asx women considering pregnancy
(3)
- severe rheumatic MS with favorable morphology: PMBC @ CVC (2a)
- severe AS: “intervention” (2a)
- severe MR suitable for rx: MVRx @ CVC (2b)
recommendation re: valve choice in women of childbearing age
bp > mech d/t increased maternal & fetal risks a/w mech during preg (2a)
can still choose mechanical (SDM valve choice=class 1)
How is PPM (patient-prosthesis mismatch) measured/assessed?
iEOA = indexed effective orifice area ≈ AVA:BSA
- mild >0.85
- mod 0.65-0.85
- sev <0.65
iEOA (~AVA:BSA) <0.65
severe PPM
iEOA (~AVA:BSA) = 0.65-0.85
moderate PPM
iEOA (~AVA:BSA) >0.85
mild PPM / “at risk”
location of Manouguian root enlargement
L-non (LCC-NCC) commissure into the inter-leaflet triangle & AMC
https://drive.google.com/file/d/10U7clNgAMS3P8ZZUWH4j–aytUB02oQ1/view
https://drive.google.com/file/d/10dvR70BSSF7sNMwU1PtJQ_bkkV9KBrFI/view
location of Manouguian root enlargement
L-non (LCC-NCC) commissure into the inter-leaflet triangle, aorto-mitral curtain, and anterior mitral valve leaflet
1-1.5cm into the leaflet; do not enter LA roof (sweep away from root)
https://drive.google.com/file/d/10U7clNgAMS3P8ZZUWH4j–aytUB02oQ1/view
https://drive.google.com/file/d/10dvR70BSSF7sNMwU1PtJQ_bkkV9KBrFI/view
farthest proximal (deepest) extent of Manouguian root enlargement
onto the anterior mitral valve leaflet
1-1.5cm into the leaflet; do not enter LA roof (sweep away from root)
https://drive.google.com/file/d/10U7clNgAMS3P8ZZUWH4j–aytUB02oQ1/view
https://drive.google.com/file/d/10dvR70BSSF7sNMwU1PtJQ_bkkV9KBrFI/view
farthest proximal (deepest) extent of Manouguian root enlargement
onto the anterior mitral valve leaflet
1-1.5cm into the leaflet; do not enter LA roof (sweep away from root)
https://drive.google.com/file/d/10U7clNgAMS3P8ZZUWH4j–aytUB02oQ1/view
https://drive.google.com/file/d/10dvR70BSSF7sNMwU1PtJQ_bkkV9KBrFI/view
maximum increase in annular size achievable with Manouguian root enlargement
4mm
maximum increase in valve size achievable with Manouguian root enlargement
+2 valve sizes
location of Nicks root enlargement
through the midpoint of non (NCC) sinus
https://drive.google.com/file/d/10rQzLHVuQDElGEBX91M-yoY-k2DrAAHq/view
location of Nicks root enlargement
through the midpoint of non (NCC) sinus into the fibrous subaortic curtain
https://drive.google.com/file/d/10rQzLHVuQDElGEBX91M-yoY-k2DrAAHq/view
farthest proximal (deepest) extent of Nicks root enlargement
up to but not into mitral valve
“as far as the origin of the mitral valve”
https://drive.google.com/file/d/10gKWb9g-ToZNXP3VNAQ5KcvluEPe8uO-/view
maximum increase in annular size achievable with Nicks root enlargement
2mm
maximum increase in valve size achievable with Nicks root enlargement
+1 valve size
location of Konno root enlargement
through R (RCC) sinus (4-5mm lateral to/leftward of RCA) into interventricular septum + 2nd incision in anterior wall of RVOT
What structure do you have to worry about under the L-non (LCC-NCC) AV commissure?
anterior mitral valve leaflet / aorto-mitral curtain
What structure do you have to worry about under the R-non (RCC-NCC) AV commissure?
membranous septum, which contains LBB/bundle of His
What structure do you have to worry about behind the non sinus / non-R (NCC-LCC) commissure?
AV node
AVR sutures (normal)
pledgeted horizontal mattress from ventricular->aortic
AVR sutures at a root enlargement patch
pledgeted horizontal mattress from outside->in
standard quantity of Del Nido cardioplegia (total)
1200mL
interval to re-dose Del Nido cardioplegia
Q1H
quantity of Del Nido cardioplegia for retrograde
500mL
quantity of Del Nido cardioplegia for antegrade
700mL
quantity of Del Nido cardioplegia for ostial
RCA: 300mL
LCA: 400mL
total: 700mL
ONLY valve(s) for which intervention on moderate regurg is indicated
AR
- concomitant <3 surg (2a)
TR
- progressive + concomitant <3 L valve surg + annulus EDD>40mm OR prior RH fail sxs (2a)
ONLY valve(s) for which intervention on moderate dysfxn is indicated
AS
- concomitant <3 surg (2b)
AR
- concomitant <3 surg (2a)
TR
- concomitant <3 L valve surg + annulus EDD>40mm (2a)
- concomitant <3 (L valve) surg + prior RH fail sxs (2a)
MS
- NYHA ≥II + MVA>1.5 + PAWP>25 OR mean grad >15 with exercise ⇒ PBMC (2b)
ONLY valve(s) for which intervention on moderate stenosis is indicated
AS
- concomitant <3 surg (2b)
MS
- NYHA ≥II + MVA>1.5 + PAWP>25 OR mean grad >15 with exercise ⇒ PBMC (2b)
ONLY valve(s) for which intervention outside of concomitant <3 surg on moderate dysfxn is indicated
MS
- NYHA ≥II + MVA>1.5 + PAWP>25 OR mean grad >15 with exercise ⇒ PBMC (2b)
only AHA recommendation for warfarin over DOAC for anticoag for afib
afib + rheumatic MS (1)
AHA recommendation for anticoag for afib with rheumatic MS
warfarin (1)
AHA recommendation for anticoag for afib with any valvular dz except rheumatic MS
DOAC (1)
(per CHADS-VASc score)
STS risk score (%):
low-risk
<4%
STS risk score (%):
intermediate-risk
4-8%
STS risk score (%):
high-risk
>8%
STS risk score = risk of what outcome/endpoint (for risk-stratification)
death
Modified Duke criteria for definite endocarditis dx
definite IE criteria:
- 2 major
- 1 major + 3 minor
- 5 minor
Modified Duke criteria for possible endocarditis dx
poss IE criteria:
- 1 major + 1 minor
- 3 minor
Modified Duke major criteria for endocarditis dx
- ⊕blood cxs x2 with common bx
- ECHO (updated: or cardiac CT) signs (veg, leaflet perf, valve aneurysm, abscess, pseudoaneurysm, intracard fistula, NEW regurg, new partial dehisc of prosthetic valve)
Modified Duke minor criteria for endocarditis dx
- predisposition: incl heart condition, IVDU, h/o endocarditis, prosthetic valve, h/o valve rx, CHD, HOCM
- fever >100.4°F (38°C)
- vascular phenomena: septic emboli (incl Janeway lesions), mycotic aneurysm
- immunologic phenomena: glomerulonephritis, Osler’s nodes, Roth’s spots, rheumatoid factor
- micro: ⊕blood cx not meeting major criterion OR ⊕serology for organism c/w IE
AHA indication(s) for “early surgery” in endocarditis
early = during initial hospitalization & before abx course completed
- valve dysxfn ⇒ HF sxs (1)
- L-sided highly-resistant organism (S. aureus, fungus) (1)
- heart block / annular or Ao abscess / destructive penetrating lesions (1)
- persistent bacteremia or fevers >5d after abx (1)
- recurrent emboli/persistent veg (2a)
- L-sided native valve with mobile veg >1cm length (2b)
AHA “early surgery (during initial hospitalization and before completion of a full therapeutic course of antibiotics)”