INTERN TALKS

Sherrie Khadanga MD

Case presentation

A 52-year-old woman presents with a 1-week history of fever, chills, fatigue, and pain in her L.leg.

PMH: hypothyroidism Med: synthroid, Motrin PRN Allergies: none FH: non-contributory Social hx: denies any drug use but smokes

cigarettes and occasionally drinks 1-2 glasses of wine per week. Works as a pre-school teacher

Vitals: Tmax 39.2ºC, HR111, BP 118/70, RR 16

Physical exam: GEN: NAD, AAOx3 CV: 2/6 holosytolic murmur best heard at

RUSB PULM: CTAB ABD: NT, ND, +BS Extremities: L.ankle-warm and

erythematous; painful on dorsiflexion

Pertinent labs: H/H– 11&28 (mild anemia new) WBC– 28 Blood cultures x2 TEE– 9cm vegetation on mitral valve

Diagnosis: Infective Endocarditis

Clinical question: What is the appropriate management for a pt with IE who is relatively stable with a moderate size vegetation?

Original Article Early Surgery versus Conventional Treatment for

Infective Endocarditis

Duk-Hyun Kang, M.D., Ph.D., Yong-Jin Kim, M.D., Ph.D., Sung-Han Kim, M.D., Ph.D., Byung Joo Sun, M.D., Dae-Hee Kim, M.D., Ph.D., Sung-Cheol Yun, Ph.D., Jong-Min

Song, M.D., Ph.D., Suk Jung Choo, M.D., Ph.D., Cheol-Hyun Chung, M.D., Ph.D., Jae-Kwan Song, M.D., Ph.D., Jae-Won Lee, M.D., Ph.D., and Dae-Won Sohn, M.D., Ph.D.

N Engl J MedVolume 366(26):2466-2473

June 28, 2012

Background

Early surgery is indicated for patients with infective endocarditis and CHF but indications for surgical intervention to prevent systemic embolism has not been clearly defined

ACC-AHA guidelines (2006) recommend early surgery as a class IIa indication only in patients with recurrent emboli and persistent vegetation

European Society of Cardiology guidelines (2009) recommend early surgery as a class IIb indication in patients with isolated lg vegetation (>15mm)

Indications for and Timing of Surgery in Patients with Left-Sided, Native-Valve Infective Endocarditis

Purpose of Study

Timing and indications for surgical intervention to prevent systemic embolisms remain controversial

The EASE trial was conducted to compare clinical outcomes of early surgery and conventional treatment in patients with infective endocarditis of the native valves

The major hypothesis was that early surgery would decrease the rate of death or embolic events as compared with conventional treatment

Patients were randomly assigned in a 1:1 ratio to the early surgery group or conventional treatment

Treatment assignments were computer generated and stratified according to the involved valve

Those in the early surgery group underwent surgery 48 hours after randomization

Patients assigned to conventional treatment group were treated according to AHA guidelines and surgery was performed only if complications requiring urgent surgery developed during medical treatment or if symptoms persisted after completion of antibiotic therapy

Clinical and Echocardiographic Characteristics of the Patients at Baseline, According to Treatment Group.

-Study conducted from Sep ‘06- March ‘11-total of 76 patients enrolled-mean age- 47 years old-67% male-mitral valve involved in 45 patients -aortic valve involved in 22 patients-9 patients had involvement of both valves-median diameter of vegetation-12mm-most common pathogen in both groups:

-Viridans 30%-S.aureus 11%

Characteristics of Antibiotic Therapy, According to Treatment Group.

Statistical Analysis

Estimated that a sample of 74 patients would provide 80% power to detect a significant difference with respect to the primary end point

Analyses were performed with intention to treat

Since randomization was stratified according to involved valve, stratified Cox proportional hazards progression analyses were done for the outcomes

Clinical End Points

Primary End Point: Composite of in-hospital death or clinical embolic events that occurred within 6 weeks after randomization

An embolic event was defined as acute onset of symptoms or signs of embolism or occurrence of new lesions

Secondary end points (at 6 months): -death from any cause-embolic events -recurrence of IE-repeat hospitalization due to dev of CHF

Kaplan–Meier Curves for the Cumulative Probabilities of Death and of the Composite End Point at 6 Months, According to Treatment Group

Discussion

Systemic embolism which occurs roughly in 1/3 of patients with IE and often involves CNS (65%), is the second most common cause of death (after CHF)

In this study, in hospital and 6 month mortality in both groups was substantially lower than that reported previously Proportion of patients with poor prognostic

factors were lower compared to other studies Moderate to severe CHF, AMS, staph infections

Limitations

Limited in scope– pts excluded were those with major stroke, IE with prosthetic valve, or aortic abscess

Incidence of S.aureus was lower than in previous studies

Patients in this study had low operative risk

Conclusions

As compared with conventional treatment, early surgery in patients with infective endocarditis and large vegetations significantly reduced the composite end point of death from any cause and embolic events by effectively decreasing the risk of systemic embolism.