Diapositive 1

Endocardite Infectieuse : Rle de lEchocardiographieJean-Luc MONIN, CHU Henri Mondor, CrteilRemerciements: Pr. Gilbert HABIB, CHU La Timone, Marseille

21me Congrs du Collge National des Cardiologues FranaisParis, 8-10 octobre 2009Henri MondorRole of Echocardiography in Infective Endocarditis Diagnosis

Management2Henri MondorRole of Echocardiography in Infective Endocarditis Diagnosis

Management3Henri MondorModified Duke criteria for the diagnosis ofInfective EndocarditisLi et al. Clin Infect Dis. 2000; 30: 633-8 MAJOR CRITERIA:- Blood cultures positive for IE- Echocardiography positive for IE: vegetation, abscess, new valvular regurgitation/ dehiscence of prosthetic valve MINOR CRITERIA:- Predisposing heart condition, IV drug abuse- Fever (> 38C)- Vascular phenomena: arterial emboli, mycotic aneurysms, intracranial hemorrhage, - Immunologic phenomena: Oslers nodes, Roths spots, - Bacteriological evidence: Positive blood culture but does not meet major criteria4Henri MondorClinical Suspicion of IETrans-thoracic Echocardiography Prosthetic Valve Intracardiac devicePositiveTTE Poor qualityTTETTE NegativeClinical suspicion of IE HighLowStopIf initial TEE is negative but suspicion for IE remains, repeat TEE within 7-10 daysTransesophageal Echocardiography *Habib et al. ESC Guidelines. Eur Heart J. 2009. Aug 275Henri Mondor Diagnosis of vegetation

Diagnosis of abscess

IE affecting intra-cardiac devices

Diagnosis of Infective Endocarditis by Echo:Difficulties are frequent6Henri Mondor Diagnosis of vegetation

Diagnosis of abscess

IE affecting intra-cardiac devices

Diagnosis of Infective Endocarditis by Echo:Difficulties are frequent7Henri MondorSensitivity (%)Specificity (%)Accuracy (%)VegetationsTTE (n=281)TEE (n=269)79%83% *98%99%97%99%Diagnostic value for detecting vegetations:TTE versus TEEMonin et al. J Am Coll Cardiol. 2005; 46: 302-9- In 80 cases of endocarditis, sensitivity for the detection of vegetation was 58% for TTE versus 90% for TEE (p= 0.001).* P= NS : TTE versus TEEMugge et al. J Am Coll Cardiol. 1989; 14: 631-88Henri MondorNunesApical 4-chamber view

Henri Mondor

Henri MondorNunesApical 4-chamber (Lower plane)

Henri Mondor

Henri Mondor

NunesCommissural leak (C2)Color Flow Doppler

Henri MondorHenri MondorClinical Suspicion of IETrans-thoracic Echocardiography Prosthetic Valve Intracardiac devicePositiveTTE Poor qualityTTETTE NegativeClinical suspicion of IE HighLowStopIf initial TEE is negative but suspicion for IE remains, repeat TEE within 7-10 daysTransesophageal Echocardiography *Habib et al. ESC Guidelines. Eur Heart J. 2009. Aug 2712Henri Mondor

NunesTEE : Inter-commissural plane

Henri MondorHenri Mondor

NunesInter-commissural plane + CFD

Henri MondorHenri Mondor Very small (< 2 mm) vegetation

Non vegetant endocarditis

Prosthetic and pacemaker endocarditis

Mitral valve prolapse with thickened valves

Vegetation not yet present or already embolizedEchocardiography (even Transesophageal) is not 100% sensitiveA negative TEE does not rule out endocarditisIf initial TEE is negative but suspicion for IE remains, repeat TEE within 7-10 daysHabib et al. ESC Guidelines. Eur Heart J. 2009. Aug 2715Henri Mondor Diagnosis of vegetation

Diagnosis of abscess

IE affecting intra-cardiac devices

Diagnosis of Infective Endocarditis by Echo:Difficulties are frequent16Henri MondorAbscess of the aortic root

- Better assessed by TEE

- Multiple views to assess abscess extension

- Difficult diagnosis at the early stage of the disease

- Need for frequent TEE controls if non operated Courtesy: Pr. C. Tribouilloy17Henri Mondor

Abscess of the aortic root:Better assessed by TEECourtesy: Pr. C. Tribouilloy18Henri Mondor

Abscess of the aortic root:Better assessed by TEECourtesy: Pr. C. Tribouilloy19Henri Mondor Diagnosis of vegetation

Diagnosis of abscess

IE affecting intra-cardiac devices

Diagnosis of Infective Endocarditis by Echo:Difficulties are frequent20Henri MondorProsthetic valve endocarditis- Better assessed by TEE

- Especially in the mitral position

- Reverberations/ artifacts due to the prosthesis

- Need for frequent TEE controls if non operated

Postoperative D-4521Henri Mondor

Prosthetic valve endocarditis:The role of Transesophageal EchoPostoperative D-4522Henri Mondor

Adapted antibiotics (D+10)Prosthetic valve endocarditis:Repeat TEE if non operated23Henri Mondor

Prosthetic valve endocarditisAdapted antibiotics (D+10)24Henri MondorRole of Echocardiography in Infective Endocarditis Diagnosis

Management25Henri MondorTiming of Surgery in Infective Endocarditis:The 2009 ESC GuidelinesINDICATIONS FOR SURGERYTiming ClassLevelA/ CONGESTIVE HEART FAILURESevere acute AR or MR or valve obstruction causing refractory pulmonary oedema / cardiogenic shockEmergencyIBAortic or mitral IE with fistula causing refractory pulmonary oedema or cardiogenic shockEmergencyIBSevere acute AR or MR or valve obstruction with persistent CHF or echocardiographic signs of poor hemodynamic tolerance (early mitral closure, pulmonary hypertension)UrgentIBSevere acute AR or MR without CHF or any sign of poor toleranceElectiveIIaBB/ UNCONTROLLED INFECTIONLocally uncontrolled: enlarging vegetation, abscess, fistula, false aneurysm)UrgentIBPersisting fever and positive blood cultures > 7-10 days of antibioticsUrgentIBIE due to fungi or multi resistant organismsUrgent/ ElectiveIBC/ PREVENTION OF EMBOLISMLarge aortic or mitral vegetations (>10 mm) following 1 embolic episode despite appropriate antibioticsUrgentIBLarge aortic or mitral vegetations (>10 mm) with other predictors of complicated course (CHF, persistent infection, abscess)UrgentICVery large vegetations without any other risk factorsUrgentIIbCHenri MondorIndications for SurgeryTiming *ClassLevelLocally uncontrolled: enlarging vegetation, abscess, fistula, false aneurysm)UrgentIBPersisting fever and positive blood cultures > 7-10 days of antibioticsUrgentIBIE due to fungi or multi resistant organismsUrgent/ ElectiveIBTiming of Surgery in Infective Endocarditis:Indications for Uncontrolled InfectionESC Guidelines. Eur Heart J. 2009. Aug 2727Henri Mondor

Emergent surgery (the same day):Acute severe AR with pulmonary oedemaEarly mitral closure28Henri Mondor

Diastolic MREmergent surgery (the same day):Acute severe AR with pulmonary oedema29Henri Mondor

Acute severe AR with pulmonary oedema :Limitations of the PHT30Henri MondorTiming of Surgery in Infective Endocarditis:Indications for Heart FailureESC Guidelines. Eur Heart J. 2009. Aug 27Indications for SurgeryTiming *ClassLevelSevere acute Aortic or mitral regurgitation or valve obstruction causing refractory pulmonary oedema or cardiogenic shockEmergency(within 24 Hours)IBAortic or mitral IE with fistula causing refractory pulmonary oedema or cardiogenic shockEmergencyIBSevere acute AR or MR or valve obstruction with persistent CHF or echocardiographic signs of poor hemodynamic tolerance (early mitral closure, pulmonary hypertension)Urgent(within 2-3 days)IBSevere acute Aortic or mitral regurgitation without CHF or any sign of poor toleranceElectiveIIaB31Henri Mondor

9/4517/6610/2430/43178 patients, definite IE% Embolic eventsDi Salvo et al. J Am Coll Cardiol. 2001; 37: 1069-76Risk of systemic embolism according toVegetation size (TEE)32Henri MondorThuny et al. Circulation. 2005; 112: 69-75Risk of systemic embolism under appropriate antibiotics

% New Embolic Events384 patients with definite IE , European multicentre studyEmbolic events: n= 131 (34%), of which 28 (7.3%) under therapyUnder therapy: 20 events (71.4%) during the first 15 days

33Henri Mondor

Fabri et al. Int J Cardiol. 2006 ; 110 : 334-9 629 cases of IE, 133 embolic events (21.1 %)Risk of systemic embolism under appropriate antibioticsTHE RISK OF EMBOLIC EVENTS:Dramatically decreases after initiation of ATBRemains high during the first 2 weeks of ATBIs related to the size /mobility of the vegetationsMay be reduced by early surgery ?34Henri MondorESC Guidelines. Eur Heart J. 2009. Aug 27Timing of Surgery in Infective Endocarditis :Prevention of embolismIndications for SurgeryTiming *ClassLevelLarge aortic or mitral vegetations (>10 mm) following 1 embolic episode despite appropriate antibioticsUrgent(within 2-3 days)IBLarge aortic or mitral vegetations (>10 mm) with other predictors of complicated course :(CHF, persistent infection, abscess)UrgentICVery large vegetations without any other risk factorsUrgentIIbC35Henri Mondor

Isolated large vegetation > 15 mm:Urgent surgery is required (Class IIb)36Henri MondorEchocardiography plays a key role in the diagnosis and management of patients with infective endocarditisTransesophageal echo is mandatory in the majority of patientsA negative TEE does not rule out endocarditis: repeat TEE after 7-10 days if suspicion if IE remainsEarly indications for surgery (CHF, uncontrolled infection or prevention of embolism) are mainly based on echocardiography (TEE ++)

Take-Home messages37Henri Mondor

38Henri Mondor