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Sandra Rowe

on 9 May 2014

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Transcript of Endocarditis

Cut to Cure?
Early Surgery in Infective Endocarditis
Sandi Rowe, PharmD
July 26, 2012

What is Infective Endocarditis?
Early Surgery versus Conventional Treatment
for Infective Endocarditis
Duk-Hyun Kang, et al.
NEJM 366;26
June 28, 2012
Study Design
Prospective, multi-center, randomized trial in Korea
Patients were candidates for both early surgery and conventional treatment
Study Procedures

Baseline TEE
Brain/abdomen CT
1:1 computer-generated randomization by involved valve
Surgery within 48 hours
Conventional treatment per AHA guidelines
FU at 4 wks, 6 wks, 3 mos, 6 mos, 1 yr, then 6 mo intervals

Composite endpoint
In-hospital death, clinical embolic events within 6 wks of randomization
Secondary endpoints at 6 mo FU
Embolic events
Recurrence of IE
Repeat hospitalization 2/2 CHF development

Sample size of 74 patients
80% power to detect alpha 0.05
Assumed in-hospital event rate 23% in conventional group and 3% event rate in early-surgery group
Mann-Whitney U for continuous and Fisher's exact for categorical data

Little studied population
Inclusion/exclusion criteria reasonable
Duke Criteria
Little specific information about patient population was provided

Provides evidence for early surgery
Limited patient population
Reduction of embolic risk
Who Gets NVE?
Rheumatic heart disease in developing countries
Congenital heart disease
IV drug use, degenerative valve disease, health care-associated infection, intracardiac devices, hemodialysis
What Organisms Are Involved?
Superior vena cava
Right ventricle
Left atrium
Pulmonary artery
Pulmonary veins
Left ventricle
Inferior vena cava
AHA Guidelines
IE Diagnosis
Classic manifestiations
Persistant bacteremia
Evidence of vegetation
Peripheral emboli
How to diagnose in patients without classic symptoms?
Circulation 2005; 111; e39-e434.
Infective endocarditis (IE) is an infection of the endocardial surface of the heart
Valves most commonly involved
Can lead to CHF, valve insufficiency, systemic effects
Left-sided vs right-sided
Native valve endocarditis (NVE) vs Prosthetic valve endocarditis (PVE)
Karchmer AW. Braunwald's Heart Disease. Chapter 67.
Haldar SM, O'Gara PT. Hurst's The Heart. Chapter 86.
Karchmer AW. Braunwald's Heart Disease. Chapter 67.
When to perform surgery

IE unresponsive to abx
Intracardiac complications
Acute valve stenosis or regurg with HF(Class I, LoE B)
Acute AR or MR with elevated filling pressures(Class I, LoE B)
Fungal endocarditis or caused by highly resistant organisms(Class I, LoE B)
Heart block, annular or aortic abscess, destructive penetrating lesions (Class I, LoE B)
Recurrent emboli and persistent veetations despite appropriate abx therapy (Class IIa, LoE C)
Mobile vegetations >10 mm (Class IIb, LoE C)
Circulation 2005; 111; e39-e434.
Karchmer AW. Braunwald's Heart Disease. Chapter 67.
Karchmer AW. Braunwald's Heart Disease. Chapter 67.
Karchmer AW. Braunwald's Heart Disease. Chapter 67.
Karchmer AW. Braunwald's Heart Disease. Chapter 67.
Circulation 2005; 111; e39-e434.
NEJM. 2012;366:2466-73.
NEJM. 2012;366:2466-73.
NEJM. 2012;366:2466-73.
NEJM. 2012;366:2466-73.
NEJM. 2012;366:2466-73.
NEJM. 2012;366:2466-73.
NEJM. 2012;366:2466-73.
NEJM. 2012;366:2466-73.
Recommended Antibiotic Therapy
Circulation 2005; 111; e39-e434.
Full transcript