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  • • Infection of any part of cardiac endothelium (usually bacterial)

    • Valves most frequently involved

    • -Vegetations may destroy leaflets or embolize

    • Abscess formation can cause heart block or persistent sepsis

    Subacute: Symptoms for months, usually caused by hemolytic streptococci

    Acute/fulminant: Days to weeks; typically caused by S aureus

    • Result in aortic regurgitation (AR), failure, sepsis, emboli

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Epidemiology

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  • • Patients at risk for endocarditis include those with congenital or preexisting valvular defects, indwelling cardiac catheters, or prosthetic heart valves

    • Injection drug users and persons with prosthetic heart valves have highest incidence of gram-negative bacterial and fungal infections

    • Fourth leading cause of life-threatening infections in United States

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Symptoms and Signs

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  • • Fever, bacteremia, peripheral emboli

    • Immunologic vascular phenomena:

    • -Glomerulonephritis

      -Osler's nodes (painful, erythematous nodules on pulp of fingers)

      -Roth spots (retinal hemorrhages)

    • Subungual splinter hemorrhages: Peripheral hemorrhages

    • Janeway lesions: Flat, painless red spots on palms and soles of feet

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Laboratory Findings

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  • • 3 sets of blood cultures 1 hr apart: Positive

    • Culture-negative endocarditis occurs in < 5% of cases (due to antibiotics, fastidious organism, fungal infection)

    • ECG

    • -Nonspecific usually

      - PR prolongation may be seen in cases of annular abscess and is ominous

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Imaging Findings

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  • Chest film:

    • -Signs of heart failure including interstitial pulmonary edema and cardiomegaly

      -Parenchymal nodules (septic emboli) seen in right-sided heart involvement

    Echocardiography: Document location and degree of valve involvement, vegetation size, presence of annular abscess

    Catheterization: Contraindicated if aortic valve vegetations or annulus abscess

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  • • Evaluate for other sites of endovascular infection

    • Evaluate for secondary effects on cardiac muscle function

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  • • Vegetations > 1 cm (especially on mitral valve) have higher risk of embolization

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  • • IV antibiotics

    • Acute AR from endocarditis poorly tolerated

    • -Pulmonary edema, congestive heart failure rapid

    • AV replacement with allograft preferred due to high resistance to infection

    • Mitral valve repair with debridement of vegetation and pericardial patch reconstruction is possible in a small fraction of patients

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Surgery

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Indications

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  • • Severe valvular regurgitation with heart failure

    • Abscess of valve annulus

    • Persistent bacteremia > 7 days with adequate antibiotic therapy

    • Fungal or gram-negative bacterial infection

    • Recurrent emboli

    • Mobile vegetations > 1 cm

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Prognosis

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  • • Untreated mortality is nearly 100%; parenteral antibiotics, 30-50% mortality

    • Overall mortality with antibiotics and surgery is 10%

    • Many injection drug users die of prosthetic valve infection or drug overdose after repair

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References

Moon MR et al. Treatment of endocarditis with valve replacement: the question of tissue versus mechanical prosthesis. Ann Thorac Surg. 2001;71:1164.  [PubMed: 11308154]
Ferguson E et al. The surgical management of bacterial valvular endocarditis. Curr Opin Cardiol. 2000;15:82.  [PubMed: 10963143]

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