Infective Endocraditis- Aortic Stenosis

Question 1

A 56 years old lady with Bicuspid Aortic Valve Is admitted for laparotomy.
Q1: Why is Bicuspid Aortic Valve susceptible to IE?

Answer 1

because valve has 2 flaps only  narrowing and obst  stasis and bacteria can colonise and infect it.

Question 2

Q3. Investigation identify Vegetations In infective Endocarditis?

Answer 2

2D ECHO

Question 3

Q2: Pathogenesis of Infective Endocarditis in Bicuspid valve?

Answer 3

Narrowing of the valve – > stasis of blood – > bact. Colonisation and damage – > recurrent inflammation will cause progressive fibrosis, narrowing and stiffning – > further stenosis.

Question 4

Q4: What are you looking for in 2D echo?

Answer 4

Valvular regurge /
Vent. Dilatation /
leaflet prolapse /
Pericardial effusion /
Annular prolapse.

Question 5

Q5: What is the cause for sudden death in AS?

Answer 5

Acute MI / Aortic Diss.

Question 6

Q7: Pathophysiology of Aortic Stenosis/How does AS lead to death?

Answer 6

Sclerosis  Stenosis  Vent Hypertrophy  less elstiicity  less coronary blood flow  increase in myocardial work load and O2 consumption – > death.

Question 7

Q6: Clinical picture of Aortic Stenosis?

Answer 7

Mild – > Asym.
Mod – > angina / Syncope / Dyspnea of exeretion
Sever – > HF complications and Symp may lead to sudden death.

Question 7

Q9: What is the difference between Mechanical and Tissue Valve?

Answer 7

Mech; Good durability and less re-op / Easy to insert / Needs warfarin / Relative high risk of TE and bleeding
Tissue; Noiseless / Diff to insert / No warfarin and Relative low risk for bleeding and TE

Question 7

Q10: what is the non-surgical option for Valve replacement?

Answer 7

TAVR

Question 8

Q8: What are the surgical options to treat Aortic Stenosis?

Answer 8

Mechanical Valve Replacement / Tissue valve replacement / TAVR / Balloon valvoplasty

Question 9

Q12: what is the commonest Bacteria cause infection of prosthetic valve?

Answer 9

HACEK group
Staph. Epid / Aureus

Question 9

Q11: If metallic valve replacement was done and the patient developed Infective Endocarditis what will be your next step? Why?

Answer 9

Remove valve as it becomes septic focus, valve will be dehiscent
and Abx will not work as there’s no blood supply for the valve and also the biofilm around it.

Question 9

Q13: If you find microscopic branching Hyphae on the removal of the valve, What is the cause? Types?

Answer 9

Fungal Inf.
By; Candida / Aspergillosis

Question 10

Q14: A patient with Mechanical valve replacement after a while Started complaining of Arm weakness? Why?

Answer 10

Thromboembolism  cerebrovascular Stroke (arm weakness)

Question 11

Q15: Do you prescribe anti-coagulant post valve replacement?

Answer 11

Yes For 3 months

Question 12

Q16: what is the common anti-coagulant used with outpatients?

Answer 12

Warfarin

Question 13

Q. which pathway not affected by Warfarin?

Answer 13

Ext. Pathway

Question 13

Q17: Mode of action of Warfarin?

Answer 13

Inhibition of Vit K dependent Coagulation Fx

Question 14

Q19: Describe the common pathway of Clot formation ?

Answer 14

Prothrombin –(F10a)– > Thrombin
Fibrinogen –(Thrombin)–> Fibrin
Later on by F13a –> stabilization

Question 15

Q. What does activate Factor 10?

Answer 15

Calcuim

Question 16

Q20: Define Thrombus?

Answer 16

Solid material from that formed from blood coagulation products and it’s attached to the wall

Question 17

Q21: What type of complication happen to non-displaced Thrombus ?

Answer 17

Infection / Dislodgment

Question 18

Q22 what test you will do if you suspect that thrombus is infected?

Answer 18

Labs; CRP ESR and blood culture

Question 19

Q23: What is CRP? What you look for in Blood Culture?

Answer 19

Acute phase reactant ptn produced by liver in response to acute inflammation.(Cytokines) stimulated by Inf. Inflam, trauma.
Looking for G+ve / G-ve / Anarobes
(Staph Aureus / Strept V. / Enetrococcus)

Question 19

Q24: What is type of endocarditis that occur with adenocarcinoma ?

Answer 19

Libman Sac

Question 19

Q25: what is the Antibiotic guide lines in patient with Aortic Stenosis?

Answer 19

Acc to NICE guidelines – only Abx in case of Highly infectious procedures
SIGN guidelines – No need for Abx at all

Question 20

Q. Hand signs in IE

Answer 20

Janway lesions – Osler nodes -splinter Hge

Question 21

Acshoff Nodules

Answer 21

 Gran. Inflam, composed of fibrinoid necrosis surrounded by chronic inflammatory cells, including macrophages (Aschoff cells), lymphocytes, and plasma cells