valvular heart disease, congenital heart disease and infective endocarditis

Question 1

what side of the heart does valvular heart disease affect the most?

Answer 1

LHS

Question 2

what valves are affected? and where are they situated?

Answer 2

aortic valve- between LV and aorta
mitral valve- between LV and LA

Question 3

what causes valvular heart disease?

Answer 3

-age
-congenital
-IE- bacteria on heart valves
-Rheumatic fever- complication of streptococcal infection

Question 4

what are the two pathologies of valvular heart disease?

Answer 4

1- regurgitation
2-stenosis

Question 5

what happens during regurgitation?

Answer 5

• heart valves lose structural integrity and become floppy/leaky
  -blood regurgitates back to heart chamber and blood therefore flows the wrong way
  -leads to heart failure

Question 6

what happens during stenosis?

Answer 6

-valves narrow and reduce blood flow
-inadequate outflow of blood
-leads to heart failure

Question 7

how do you treat valvular heart disease?

Answer 7

-medication to treat heart failure
-surgery

Question 8

what are the 3 ways to replace valves?

Answer 8

-biological replacement e.g porcine
-mechanical replacement- metal valves
-transcatheter aortic valve implantation (TAVI)- biological

Question 9

what is needed post surgery for biological valve replacements?

Answer 9

short term anticoagulant e.g warfarin

Question 10

what is needed post surgery for mechanical valve replacements?

Answer 10

life-long anticoagulants e.g warfarin

Question 11

what is needed post surgery for a TAVI valve replacement?

Answer 11

biological but does not require anticoagulants
- WILL require life long antiplatelet therapy

Question 12

what are the dental aspects of valvular heart disease and valve replacements?

Answer 12

anticoagulants- check INR- warfarin ranges from 2.5-3
if over 4- postpone treatment

patients will be at an increased risk of infective endocarditis= more prone to bacteria on valves- either through invasive procedures (even toothbrushing) or occur spontaneously (gingivitis or caries)

therefore- its important to maintain good OH and treat perio and caries to reduce risk.

Question 13

what congenital heart disease does not increase the risk of infective endocarditis?

Answer 13

atrial septal defect- pressure of blood in left atrium higher than right atrium.

Question 14

what may patients with congenital heart disease not be able to do in a dental surgery?

Answer 14

lie flat- as they will become breathless

Question 15

what does infective endocarditis cause?

Answer 15

bacterial vegetation on diseased, prosthetic or normal heart valves

Question 16

what are the clinical features of infective endocarditis ?

Answer 16

-prolonged febrile illness (i.e prolonged fever)
-valve degeneration/failure
-embolic disease (vegetation travels through circulation to another part of body e.g brain/skin)
-kidney failure

Question 17

how would you diagnose infective endocarditis?

Answer 17

-blood culture- to determine antimicrobial therapy
-echocardiogram - may see vegetation

Question 18

what is the treatment for infective endocarditis?

Answer 18

-surgery/replacement
-prolonged course of IV antibiotics (4+ weeks)

Question 19

what is the dose for adult patients with no penicillin allergy?

Answer 19

amoxycillin- 3g 60 mins before

Question 20

what is the dose for child patients with no penicillin allergy?

Answer 20

amoxycillin- 50mg/kg max 600mg

Question 21

what is the dose for adult patients with a penicillin allergy?

Answer 21

clindamycin- 600mg

Question 22

what is the dose for child patients with a penicillin allergy?

Answer 22

clindamycin- 20mg/kg max 600mg

Question 23

list those at risk of infective endocarditis?

Answer 23

-those with acquired valvular heart disease with regurgitation or stenosis
-those with prosthetic valve replacements
-those who have had pervious IE
-those with congenital heart disease (except atrial septum defect)
-hypertrophic cardiomyopathy (genetic condition)

Question 24

what patients should be under consideration for antibiotic prophylaxis?

Answer 24

-those with prosthetic heart valve replacements
-those with previous IE
-those with congenital heart disease (except atrial septum defect)

Question 25

what should you explain to patients about antibiotic prophylaxis?

Answer 25

-risks/benefits of ab prophylaxis
-why it is not routinely used- evidence/resistance
-symptoms of IE
-the importance of good OH

Question 26

who should you contact before treatment of high risk infective endocarditis patient?

Answer 26

their cardiologist

Question 27

what resources should you utilise to assist your decision making when treating patients at risk of infective endocarditis?

Answer 27

NICE and SDCEP