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2015 ESC Guidelines For Management of IEEuropean Heart Journaldoi:10.1093, 29 August 2015Presenter- Dr Abhishek Rathore MD

Chairpersons- Prof Dr Rangaraj Ramalingam DMDr Rajeev A. DM

SRI JAYADEVA INSTITUTE OF CARDIOVASCULAR SCIENCE AND RESEARCH,BANGALORE

Salient features of ESC 2015 for IEBoosted the role of imaging in diagnosis

While the 2009 guidelines focused on echo, the 2015 guidelines show the important role of PET-CT and SPECT/CT.

Guidelines recommend that an Endocarditis Team operating in a reference centre is crucial for the management of IE Reference centres should have immediate access to diagnostic procedures and cardiac surgery.

A multidisciplinary approach is mandatory

ContManagement by an Endocarditis Team in a reference centre is one of the most important new recommendations.

Also new are recommendations for specific situations including IE in the ICU, IE associated with cancer, and marantic (non-bacterial) IE.

Important recommendations are given for the combination of early diagnosis, early antibiotic therapy and early surgery

The 2009 guidelines were the first to introduce the concept of optimal timing of surgery in patients with IE and this is highlighted again in 2015."

ContFocus on prevention rather than prophylaxis to reduce the incidence of IE, particularly in the field of nosocomial (hospital-acquired) endocarditis

Because there was no real scientific proof of its efficacy and it may be potentially dangerous.

Thus,antibiotic prophylaxiswas recommended only for patients with the highest risk of IE undergoing the highest risk dental procedures.

Restrictions for Antibiotic ProphylaxisThe risk of IE related more to low-grade bacteraemia during daily life rather than sporadic high-grade bacteraemia after dental procedures.

Most casecontrol studies did not report an association between invasive dental procedures and the occurrence of IE.

Avoid 1 case of IE per 150 000 dental procedures and 1 per 46 000 for procedures unprotected by antibiotics.

Small risk of anaphylaxis

Emergence of resistant microorganisms.

The effect of bacteraemia in humans is controversial. (Proven in animals only)

No prospective RCT has investigated the efficacy of antibiotic prophylaxis on the occurrence of IE.

The Endocarditis TeamNo single practitioner will be able to manage full spectrum of IE.

A very high level of expertise is needed from several specialties, including cardiologists, cardiac surgeons, ID specialists, microbiologists, neurologists, neurosurgeons, experts in CHD and others.

About 50% patients with IE undergo surgery during the hospital course. Early discussion with the surgical team is important and is considered mandatory in all cases of complicated IE.

Complicated IE [i.e. endocarditis with heart failure (HF), abscess or embolic or neurological complications].

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Such a team approach has been recommended recently as class IB in the 2014 AHA/ACC guideline for the management of patients with VHD.

Characteristics of the Endocarditis Team When to refer a patient with IE to an Endocarditis Team in a reference centre:

1. Patients with complicated IE should be referred early.

2. Patients with non-complicated IE can be initially managed in a nonreference centre, but with regular communication with the reference centre, consultations with the multidisciplinary Endocarditis Team, and, when needed, with external visit to the reference centre.

Characteristics of the reference centre

1. Immediate access to diagnostic procedures, including TTE, TOE, multislice CT, MRI, and nuclear imaging.

2. Immediate access to cardiac surgery.

3. Several specialists should be present on site (the Endocarditis Team), including cardiac surgeons, cardiologists, anaesthesiologists, ID specialists, microbiologists and, when available, specialists in valve diseases, CHD, pacemaker extraction, echocardiography and other cardiac imaging techniques, neurologists, and facilities for neurosurgery and interventional neuroradiology .

Role of the Endocarditis Team

1. It should have meetings on a regular basis in order to discuss cases, take surgical decisions, and define the type of follow-up.

2. They chooses the type, duration, and mode of follow up of antibiotic therapy, according to a standardized protocol, following the current guidelines.

3. They should participate in national or international registries, publicly report the mortality and morbidity of their centre, and be involved in a quality improvement programme, as well as in a patient education programme.

4. The follow-up should be organized on an outpatient visit basis at a frequency depending on the patients clinical status (ideally at 1, 3, 6, and 12 months after hospital discharge, since the majority of events occur during this period).

HLAR- High Level Aminoglycoside Resistance37

Antibiotic Treatment Of Blood Culture Negative Infective Endocarditis (BCNIE)

SURGICAL MANAGEMENT

Indication for surgical treatment of right sided infective endocarditis

Cardiac device related infective endocarditis (CDRIE)

Infective endocarditis in the ICUThe incidence of nosocomial infection is increasing and patients may develop IE

Admitted to the ICU due to haemodynamic instability related to severe sepsis, overt HF and/or severe valvular pathology or organ failure from IE-related complications

Staph is M.C. f/b streptococcus f/b fungal

There should be a relatively low threshold for TOE in critically ill patients with S. Aureus

multidisciplinary Endocarditis Team environment should be created.

I.E. during pregnancy

Incidence 0.006%.Higher inpatients with cardiac disease and further more in pt with prosthetic valves.Maternal mortality ~33%.Foetal mortality ~29%.Rapid detection and appropriate treatment is important.Despite the high foetal mortality , urgent surgery should be performed in pt who present with HF due to acute regurgitation.

I.E. In congenital heart diseases

Fewer systematic studies.

Incidence is lower in children(o.o4% per year ) than in adult(0.1%)

CHD with multiple lesion is at higher risk than simple lesion.

Mortality of 4-10 %. Prognosis is better than other forms.

Surgical repair of CHD reduces the risk, provided there is no residual shunt.

Artificial valve substrate may increase the risk.

Non-bacterial thrombotic endocarditisSterile vegetations consisting of fibrin and platelet aggregates on cardiac valvesNeither bacteraemia nor with destructive changes of the underlying valveAssociated with CTD, autoimmune disorders, hypercoagulable states, septicaemia, severe burns, tuberculosis, uraemia or AIDSA potentially life-threatening source of thromboembolism,

ContInitial diagnostic workup- same

Strong suspicion if- presence of a heart murmur, the presence of vegetations not responding to antibiotic and evidence of multiple systemic emboli

Small, broad based and irregularly shaped.

TOE should be ordered when there is a high suspicion

Immunological assays for APLA syndrome (i.E. Lupus anticoagulant, anticardiolipin antibodies, and anti-b2- glycoprotein 1 antibodies; at least one must be positive for the diagnosis of APLA on at least two occasions 12 weeks apart)

Anticoagulated with UFH or LMWH or warfarin, although there is little evidence to support this strategySurgery, valve debridement and/or reconstruction are often not recommended unless the patient presents with recurrent thromboembolism despite well-controlled anticoagulation.Other indications for valve surgery are the same as for IE

Infective endocarditis associated with cancerIE may be a potential marker of occult cancers.

In a large, Danish,nationwide, population-based cohort study, 997 cancers were identified among 8445 IE patients with a median follow-up of 3.5 years.

Risk of abdominal and haematological cancers was high (within the first 3 months)

S. bovis infection, specifically S. gallolyticus subspecies-- colonic adenoma or carcinoma.

it is recommended to rule out occult colon cancer during hospitalization and annual colonoscopy.