Role of echocardiography in the hemodynamic monitorization ...
The Role of Echocardiography · 2016-04-13 · Endocarditis: The Role of Echocardiography Pravin V....
Transcript of The Role of Echocardiography · 2016-04-13 · Endocarditis: The Role of Echocardiography Pravin V....
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Endocarditis:The Role of Echocardiography
Pravin V. Patil, MD FACC
Lewis Katz School of Medicine
at Temple University
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Acknowledgments
Dr. Susan Wiegers
Dr. Martin Keane
Temple Cardiac Sonographers
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Disclosures
No relevant financial disclosures
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Question 1
Which of the following represents the
specificity of transthoracic echo for IE?
A. 60-70%
B. 30-40%
C. 90-100%
D. <10%
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Question 2
What is the following most suggestive of?
A. Bicuspid Aortic valve
B. Aortic root abscess
C. Coronary aneurysm
D. Mitral perforation
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Question 3
What does this clip demonstrate?
A. Prosthetic valve stenosis
B. Prosthetic valve endocarditis
C. Mitral valve endocarditis
D. Aortic dissection
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Question 4Which is most likely endocarditis
A.
B.
C.
D.
A B
C D
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Endocarditis
> 50,000 cases/yr in US (47,000 Medicare hospitalizations/year)
Left sided - Majority of cases
Highest mortality and complication rate
Review
– Guidelines for prophylaxis
– Diagnosis and indications for TEE
– Identification of complications
– Prognostic (echocardiographic) features
– Indications for surgery
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ICE-PCS
41,000+ hospitalized cases of IE
30% 1 month mortality
33% of patients had CHF
In-hospital mortality (without CHF) 13%
Keifer T et al. JAMA 2011
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Prevention
Antibiotic prophylaxis recommended:
– Prosthetic heart valves or prosthetic material
valve repair
– History of endocarditis
– Heart transplant with abnormal valve function
– Certain congenital heart defects
• Cyanotic heart disease, not fully repaired
• Within 6 months of repair of defect
• Repairs with residual defects and/or leaks
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Infective Endocarditis Prophylaxis
NOT recommended for:
– Transesophageal echocardiography
– EGD
– Colonoscopy
– Cystoscopy without ongong infection
Regardless of valvular/endocarditis risk
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Diagnosis
At least 2 sets of blood cultures
Modified Duke Criteria for suspected IE
Transthoracic recommended in those with
suspected IE
– Assess for vegetations
– Assess hemodynamic severity of valve lesions
– Assess cardiac function
– Re-evaluation for clinical change/symptoms
Nishimura et al. Valvular Heart Disease Guidelines, JACC 2014
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Modified Duke Criteria
Definite infective endocarditis
– Clinical Criteria• 2 Major criteria, or
• 1 Major criterion and 3 minor criteria, or
• 5 Minor criteria
– Major criteria• Blood culture positive
• Typical microorganism for IE (multiple variations)
• Endocarditis by imaging study
Circulation 2005;111:e394-434
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Imaging Recommendations
Nishimura et al. Valvular Heart Disease Guidelines, JACC 2014
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Echocardiography Criteria
Evidence of endocarditis
– Oscillating intracardiac mass on valve or
supporting structures, in the path of
regurgitant jets, or on implanted material in
the absence of an alternative anatomic
explanation, or
– Abscess, or
– New partial dehiscence of prosthetic valve, or
– New valvular regurgitation
Circulation 2005;111:e394-434
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Echocardiography
Transthoracic
Resolution ~ 3-4 mm
Sensitivity: 62-82%
Specificity: 91-100%
Readily available, usual
initial test of choice
Transesophageal
Resolution ~ 1-2 mm
Sensitivity: 87-100%
Specificity: 91-100%
Greater (3-4x) sensitivity
for prosthetic valves
Jacob S et al. Curr Opin Cardiol 2002;Kini V et al. JASE 2010; Pederson WR et al. Chest 1991
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Case
58 yo Female, chronic IV drug abuse
presents with fever and malaise. +Blood
cultures (MSSA). Acute HF
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Underwent a robotic mitral valve repair with resection of the posterior leaflet scallop.
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Leaflet Aspect
Infective endocarditis– More commonly seen on the upstream aspect
• Ventricular surface of AV with AI
• Atrial surface of MV with MR
– Usually at a site of endothelial damage
Downstream Aspect– Usually a degenerative finding
– Papillary fibroelastoma
– Chordal structure (MV)
– Less likely associated with significant regurgitation
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Downstream Aspect
Lambl’s Excrescence Papillary Fibroelastoma
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Downstream Aspect
47 Male presenting with DVT and PE
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Case
49 yo Male with a progressive mandibular
infection and + blood cultures (Strep pneumo)
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Underwent a Ross procedure (pulmonary
autograft) with aortic root reconstruction
3 Days Later
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Complications of IE
Leaflet perforation
Aortic root abscess
Annular perforation
Fistula formation
Embolism
Purulent pericarditis
Hardware infection
Erosion
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Early Surgery
Valve dysfunction/ADHF
Resistant organisms: Staph Aureus, Fungus
Heart block or abscess formation
Large mobile vegetation
Persistent positive blood cultures
Prosthetic valve endocarditis
Fungal endocarditis
Recurrent embolization
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Case
18 yo Female present with an acute L MCA stroke
and lower extremity thromboembolism. Negative
blood cultures. New dx SLE
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Treated with SC Lovenox. Returned for followup TEE.
Moderate aortic insufficiency (improved).
Dx: Libman-Sacks Endocarditis
1 Month Later
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Differential Diagnosis
Vegetation
– Infective vs. non-infective/marantic
Lambl’s excrescence
Papillary fibroelastoma (PFE)
Thrombus
Ruptured chord
Valvular strands
Myxomatous
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Case
74 yo Male with prior
Sapien THV aortic valve
presents with a cold
left arm.
Urgent embolectomy.
+Blood cultures (Strep)
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Unable to perform TEE due to scleroderma
esophagitis. Cardiac CT and Intracardiac
echocardiogram performed to better
characterize valve.
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Intracardiac Echocardiography
Ongoing treatment with IV antibiotics and oral anticoagulation
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Size, Mobility and Embolic Events
DiSalvo et al. JACC 2001
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Location, Location, Location
Villacosta et al. JACC 2002
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Prosthetic Valve Endocarditis
Perivalvular regurgitation
Dehiscence/rocking motion
Bulging of the annulus
Necessitates TEE
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Negative TTE
TEE if clinical suspicion high
If TEE negative and clinical suspicion
persists
– REPEAT studies at 5-12 days
– Vegetations or abscess may now be present
– If still negative, look for another source
• Pacemaker, vascular grafts, catheters, PDA
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ASCeXAM Focus
Appropriate indications for TEE in IE
Echocardiographic features of vegetations
as described in modified Duke criteria
Complications of IE
Indications for surgery
Follow-up study if high suspicion and
initial study negative
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Question 1
Which of the following represents the
specificity of transthoracic echo for IE?
A. 60-70%
B. 30-40%
C. 90-100%
D. <10%
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Question 1 - Followup
Transthoracic
Resolution ~ 3-4 mm
Sensitivity: 62-82%
Specificity: 91-100%
Readily available, usual
initial test of choice
Transesophageal
Resolution ~ 1-2 mm
Sensitivity: 87-100%
Specificity: 91-100%
Greater (3-4x) sensitivity
for prosthetic valves
Jacob S et al. Curr Opin Cardiol 2002;Kini V et al. JASE 2010; Pederson WR et al. Chest 1991
Answer: 90-100%
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Question 2
What is the following most suggestive of?
A. Bicuspid Aortic valve
B. Aortic root abscess
C. Coronary aneurysm
D. Mitral perforation
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Question 2 - Followup
Answer: B. Aortic Root Abscess
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Question 3
What does this clip demonstrate?
A. Prosthetic valve stenosis
B. Prosthetic valve endocarditis
C. Mitral valve endocarditis
D. Aortic dissection
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Question 3 - Followup
Answer: B
New prosthetic valve dehiscence or
rocking motion is endocarditis until proven
otherwise
Attention to surrounding structures for
evidence of extension of infection
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Question 4Which is most likely endocarditis
A.
B.
C.
D.
A B
C D
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Question 4 - Followup
Answer: C
A B
C D
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Thank You!