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Old 09-30-2011
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Default Infective endocarditis

50 YO male with history of MVP. Presented to ER with fever 40 C. The patient reported having tooth extraction two months ago. Following admission blood cultures are positive for G+ve cocci in chains. He is treated for infectious endocarditis. The patient condition improved, fever subsided & discharged. A week later he presented with fever, tachycardia, dyspnea, rales & atrial gallop. Blood cultures are positive, ech showed decreased ejection fraction & progression of endocarditis. What is the appropriate course of management for this patient?
    • Start IV antimicrobial therapy.
    • Change antimicrobial based on culture & sensitivity.
    • Change antimicrobials & begin diuretics.
    • Surgical valve resection or replacement.
    • Change antimicrobials & add a vasodilator.
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Old 09-30-2011
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Default Surgery

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Originally Posted by ag2011n View Post
50 YO male with history of MVP. Presented to ER with fever 40 C. The patient reported having tooth extraction two months ago. Following admission blood cultures are positive for G+ve cocci in chains. He is treated for infectious endocarditis. The patient condition improved, fever subsided & discharged. A week later he presented with fever, tachycardia, dyspnea, rales & atrial gallop. Blood cultures are positive, ech showed decreased ejection fraction & progression of endocarditis. What is the appropriate course of management for this patient?
    • Start IV antimicrobial therapy.
    • Change antimicrobial based on culture & sensitivity.
    • Change antimicrobials & begin diuretics.
    • Surgical valve resection or replacement.
    • Change antimicrobials & add a vasodilator.
Heart failure in IE is indication of heart surgery and valve replacement (along with Abx, obviously), but in this case emergency cardiac surgery is indicated.
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Old 09-30-2011
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surgical valve resection or replacement.
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Old 09-30-2011
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[QUOTE=ag2011n;70789]50 YO male with history of MVP. Presented to ER with fever 40 C. The patient reported having tooth extraction two months ago. Following admission blood cultures are positive for G+ve cocci in chains. He is treated for infectious endocarditis. The patient condition improved, fever subsided & discharged. A week later he presented with fever, tachycardia, dyspnea, rales & atrial gallop. Blood cultures are positive, ech showed decreased ejection fraction & progression of endocarditis. What is the appropriate course of management for this patient?
    • Start IV antimicrobial therapy.
    • Change antimicrobial based on culture & sensitivity.
    • Change antimicrobials & begin diuretics.
    • Surgical valve resection or replacement.
    • Change antimicrobials & add a vasodilator.
[/QUOTE
Surgery in CHF
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Last edited by Aussie Guy; 09-30-2011 at 10:56 PM.
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Old 10-01-2011
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The correct answer: Surgical valve resection or replacement.
Some useful information about endocarditis:
Definition: infection of the heart valve, leads to fever & murmur.
Diagnosis: vegetation on echo & positive blood cultures. Diagnosis based on Duke’s clinical criteria: two major, 1 major & 3 minor criteria or 5 minor criteria.
Best initial test: Blood culture (95-99% sensitive). Transthoracic echo (60% sensitive, 95% specific). Transesophageal echo (95% sensitive & specific)
Etiology: Very rare to develop in normal heart valve (sever bacteremia with highly pathogenic organism S aureus with IV drug users). Regurgitation & stenotic lesions confer increased risk, prosthetic valves associated with highest risk.
Organisms:
  • Native valve endocarditis: Strep viridans is the most common. S aureus, enterococci & HACEK group.
  • Prosthetic valve endocarditis: Staphylococci are the most common cause of early onset endocarditis (< 60 days of surgery), note S epidermidis > S aureus. Streptococci are the most common cause of late onset infective endocarditis.
  • Endocarditis in IV drug users: frequently Rt sided endocarditis, most common is S aureus.
Complication:
  • Cardiac failure.
  • Myocardial abscess.
  • Solid organs damage from showered emboli.
  • Glomerulonephritis.
Immunologic phenomena includes Glomerulonephritis, Osler nodes, Roth spots, positive result for rheumatoid factor.
Surgery is the answer:
  • CHF or ruptured valve or chordae tendineae (strongest indication)
  • Prosthetic valve.
  • Fungal endocarditis.
  • Abscess.
  • AV block.
  • Recurrent emboli while on antibiotics.
Prophylaxis:
  • Significant cardiac defect:
Prosthetic valve, previous endocarditis, cardiac transplant recipient with valvulopathy, unrepaired cyanotic heart disease.
  • Risk of bacteremia: dental work with blood, respiratory tract surgery that produces bacteremia.
Genitourinary & gastrointestinal procedures, valvular heart disease (MVP, MS, MR, AS, AR), HOCM, ASD, no need for prophylaxis.
Best initial empiric therapy: Vancomycin & gentamicin.
Remember Marantic endocarditis: nonbacterial thrombotic endocarditis, in debilitating illness such as cancer, sterile fibrin 7 platelets along the valve.
Libman-Sacks endocarditis: typically involves aortic valve, small warty vegetations on both sides of the valve leaflets, may present with regurgitation murmur. In SLE.
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