valve Flashcards
Wilkin’s score
- Valve mobility
- Valve thickening
- Valve calcification
- Subvalvar thickening
MS: More than 8 bad for balloon
RFs of LV rupture post MV surgery
- excessive traction
- excessive debridement of calcium
- female
- resection of pap m.
- small left ventricle
- large prosthesis
#
name the iteology of chronic primary MR
- prolapse: myxomatous degeneration&Barlows valve (young)/fibroelastic deficiency (elderly)
- IE
- CTD (Marfans)
- rheumatic
- cleft MV
- radiation heart disease
#
Valve surgery, what age to screen for CAD?
40y.o. #
Dukes criteria
Definite I.E.: pathologic, 2major, 1major+3minor, 5 minor
Possible I.E.: 1major+1minor, 3 minor
Name the 4 major dukes criteria
- 2 Positive BC (strep viridans, strep bovis, HACEK, staph aureus, community-enterococcus)
- 1 positive BC coxiella burnetii or positive serology (anti-phase 1 IgG more than 1:800)
- Endocardial involvement
- Echo positive (oscillating intracardiac mass, abscess, new prosthetic valve dehiscence or new regurgitation)
#
HACEK ORGANISMS
Haemophilus sp. Aggregatibacter sp. Cardiobacterium hominis Eikenella corrodens Kingella sp.
Name 5 duke minor criteria
- Predisposition, heart condition, IDU
- fever more than 38deg
- Vascular phenomena (major art emboli, septic pulm infarcts, mycotoxins aneurysm, intracranial hemorrhage, conjunctival hemorrhage, janeway lesions)
- Immunologic phenomenon (glomerulonephritis, Osler nodes, Roth spots, rheumatoid factor)
- Microbio: positive BC OR positive serology
#
Lambl’s excrescence
Filiform fronds at site of valve closure; mitral more than aortic, collagen composition, can be substrate for emboli
Echo features of high risk IE
- 10mm or bigger
- Severe valve insufficiency
- Abscess or pseudo aneurysm
- Valve perforation or dehiscence
- Decompensated HF
#
Great echo predictor of embolic complications from IE
10mm or bigger veg on ant MV
Echo features that suggest early surgery for IE
Vegetation :
A. Persistent after embolization
B. Ant mitral leaflet, esp greater than 10mm
c. One or more embolic events within first 2 weeks of abx
D. Increasing veg size on abx
Valve dysfunction:
A. Acute AI or MR w ventricular failure
B. HF not responsive to Med rx
Valve perforation or rupture: A. Peri valvular extension B. Dehiscence, rupture or fistula C. new HB C. Large abscess or extension on Abx
Duke Major criteria
- Blood Culture positive for IE (2, >12 hours apart)
- single blood culture for Coxiella burnetii or anti-phase 1 IgG Ab titre greater than 1:800
- endocardial involvment
- Echo positive (oscillating intracardiac mass on valve or supporting structures, in the path of regurgitant jets, or on implanted materials; abscess; new dehiscence of prosthetic valve or new regurgitation)
Duke Minor Criteria
- predisposition (heart condition or IDU)
- temp greater than 38degrees
- vascular phenomena, major art emboli, septic pulmonary infacts, mycotic aneurysm, intracranial hmorrhage, conjunctival hemorrhage, janeway lesions
- immunological phenomena glomerulonephritis, osler nodes, roth spots, rheumatoid factor
- microbiological evidence (not meeting major criteria)
3D vs. 2D TEE
3D has lower temporal and lateral resolution
therefore, overestimates veg size and difficulty visualizing fast moving structures
define inoculum effect
which antibiotics most susceptible
which least susceptible
High bacterial density causes decreased antimicrobial activity of an antibiotic
- beta lactams and glycopeptides most susceptible to this problem (?due to loss of penicillin-binding protein during stationary-growth phase of bacteria)
- fluoroquinolones and aminoglycosides least affcted
4 common PK/PD parameters that predict antibiotic efficacy
- max serum concentration/MIC
- AUC 24/MIC
- duration of time that serum concentration exceeds MIC
- duration of postantibiotic effect
MIC = minimum inhibitory concentration
most common organisms causing early (within 1 year) prosthetic valve endocarditis
- coag neg staph
- S. aureus
- aerobic gram-neg bailli
- fungi
- corynebacterium sp
- legionella sp
most common organisms causing late PVE
- coag-neg staph
- S. Aureus
- VGS
- Enterococci
- Fungi
- Corynebacterium sp
most common organisms causing IE of indwelling devies
- S aureus
- coag-neg staph
- fungi
- aerobic gram-neg bacilli
- corynebaterium sp
most common organisms causing IE of transplantation
- S aureus
- aspergillus fumgatus
- enterococcus sp
- candida sp
most common organisms causing IE in IDU
- S aureus
- coag-neg staph
- beta hemolytic strep
- fungi
- aerobic gram-neg bacilli (inc psudomonas aeruginosa)
- polymicrobial
orgnaisms responsible for NVE in non IDU
- S aureus
- VGS or Strep gallolyticus
- enterococcus
- HACEK
- coag neg staph (s. epidermidis)
non-infectious endocarditis causes
- APA
- neoplasia associated
- atrial myxoma
- marantic endocarditis
- neoplastic D
- carcinoid - autoimmune associated
- rheumatic carditis
- SLE
- Polyarteritis nodosa
- behcet’s D - post sx
- thormbus
- stitch
- changes - Misc
- eosinophilic heart D
- ruptured mitral chordae
- myxomatous degeneration
causative agents of acute NVE
S aureus
betahemolytic trep (GAS and GBS)
aerobic gram neg bacilli
causative agents of subacue NVE
S aurus
VGS (ie. alphahemolytic strep)
HACEK
enterococci
causative agents of PVE less than 1 year
S aureus CoNStaph diphtheroids enterococci aerobic gram neg bacilli
causative agents of PVE > 1 year
staphylococci
VGS
Enerococci
mortality rates of fungal IE
more than 80%
fungal IE
- causative agents
- Rx
Candida
aspergillus
mycoses
rx:
- early Surgery
- amphotericin B + flucytosine for over 6 weeks
- lifelong suppressive rx with fluconazole
frequency of systemic embolization in IE
22-50%
organisms most likely to embolize in IE
Staph aureus
candida
HACEK
where do CNS embolizations go to?
more than 99% to MCA territorry
RFs for embolization in IE
- size (10mm on left)
- MV involvment, esp ant leaflet
- organism (Staph, candida, HACEK)
Independant predictors of mortality in IE
- DM
- S. aureus infection
- APACHE II score
- embolic events (i.e. stroke)
independent RFs of periannular extension in IE
- aortic valve involvement (10-40% NVE; 56-100% PVE)
2. current IDU
weakest point of aortic valve annulus
near membranous septum and AV node
systemic embolization sites of IE
brain, lung, coronaries, spleen, gut, extremities
define mycotic aneurysms
septic emboli to arterial vasa vasorum or intraluminal space and subsequent spread of infection from intima outwards; commonly at branching points
- intracranial
- extracranial (visceral, upper & lower extremities)
mortality rate in aorto-cavitary fistulization IE
41%
mortality rate in Intracranial mycotic aneurysms
60%
common causative agents in Intracranial mycotic aneurysms
streptococci (50%)
Staphylococci (10%)
period of greatest risk for systemic emboli in IE
before or within the first 1-2 weeks of antimicrobial therapy
indications for early surgery in IE
LEFT sided:
CLASS 1:
1. Fungal, VRE or non-HACEK Gm -ve aerobic bacilli (esp Pseudomonas aruginosa)
2. HF
3. HB, abscess, or destructive penetrating lesions
4. Persistent fever or bacteremia more than 1 week on ABx
- recurrent emboli or enlarging vegetations on ABx (IIa, B)
- severe regurge AND mobile veg greater than 10mm (IIa, B)
- veg greater than 10mm, esp on ant mitral leaflet or on prosthetic valve (IIb, C)
- relapsing PVE (IIa, C)
RIGHT sided (IIa, C)
- right HF secondary to severe TR and poor response to abx
- sustained infection with diff to treat organisms (fungal, multidrug resistant)
- lack fo resonse to abx
- TV veg greater than 20mm and recurrent PEs on Abx
process of IE development
- formation of NBTE (plt + fibrin) on valve or area of endothelial damage
- random bacteremia
- adherence of bacteria to NBTE
- proliferation of bacteria wihin a vegetation
difference between left and right sided IE lesions
Left sided lesions are uninhibited by host defenses, bacteria grows rapidly to reach 10(8)-10(12)
right sided lesions are inhibited by PMN and plt derived antibacterial proteins
x% of bacteria in both left and right sided IE vegetations are metabolically INactive
90%
thus very resistent to antibiotics
condition at risk of IE
- previous IE
- prosthetic heart valve
- Rheumatic HD
- Congenital HD
- MVP
best prevention of IE in patients with underlying predisposing cardiac conditions
improved access to dental care and increaed emphasis on oral health
pre valve surgery dental evaluation & rx
mortality risk of prosthetic vlave endocarditis is …… than native valve endocarditis
Greater
compared to NVE, PVE is more likely to
- die
- develop HF
- need Sx
- perialvular extension of infection
- other complications
worst prognosis with IE
prosthetic material + complex cyanotic CHD in children under 2
conditions with the highest risk of ADVERSE OUTCOME from IE should get prophylaxis for certain procedures
- name the conditions
- name the procedures
- name the antibiotic
CONDITIONS
- prosthetic valve material (valve/ring/band)
- previous IE
- unrepaired or incompletely repaired cyanotic CHD
- 6 months after complete repair of CHD
- post transplant valvulopathy
PROCEDURES
- all dental
- invasive respiratory tract/infected skin/infected MSK (incision & biopsy)
ABx
amoxicillin 2g PO 60min pre-procedure
or Ancef 1g IV
if allergic, give clindamycin PO or IV
SAM: when it can occur
- HOCM w basal ASH and leaflet-septal contact
- TGA w intact IVS
- post MV repair
