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Difficult decisions in infective endocarditis

Speakers

  • Difficult diagnosis of infective endocarditis: new challenges, new strategies? Presented by P Sogaard (Aalborg, DK),
  • Large vegetation: when to operate? Can we apply recommendations? Presented by A Evangelista Masip (Barcelona, ES),
  • Neurological complications; case illustrating diagnostic and therapeutic strategies. Presented by U Snygg-Martin (Goteborg, SE),
  • Panel. Presented by Peter SOGAARD (Aalborg, DK), Artur EVANGELISTA MASIP (Barcelona, ES), Ulrika SNYGG-MARTIN (Goteborg, SE), Robert DION (Genk, BE), Bernard IUNG (Paris, FR) 
Infective Endocarditis


This very exciting and interactive session tried to answer difficult questions in infective endocarditis, and to evaluate the application of 2009 ESC recommendations. Profs Robert Dion from Belgium and Bernard Iung from Paris completed the panel.

1: Difficult diagnosis of infective endocarditis: new challenges, new strategies?

The first case was presented by Peter Sogaard from Denmark. He illustrated how difficult the diagnosis of infective endocarditis may be in patients with intracardiac devices and in those with prosthetic valves.
Echocardiography, even transesophageal, is sometimes of limited value in these situations. The potential value of PET scan was underlined. In some situations, PET scan may be positive early, while TEE is still negative or doubtful. Further studies are necessary to confirm these data and give more information about the exact role of this new technique in infective endocarditis.

2 .What to do in case of large vegetation; when to operate? can we apply recommendations?

This topic was covered by Arturo Evangelista, from Spain. Embolic events are a frequent and life-threatening complication of subacute bacterial endocarditis. Several factors have been associated with the risk of embolism including the size of the vegetation ,the type of microorganism, the localization of the vegetation on the mitral valve. The most potent predictor of risk of embolism is the size and mobility of the vegetation.

The main key messages from the panel were the following:

  • Embolism occurs in 20 to 40 % of infective endocarditis, but its incidence decreases to 9 to 21 % after initiation of antibiotic therapy.
  • The risk of embolism is highest during the first days following the initiation of antibiotic therapy, and is particularly high in cases of very mobile and large (> 15 mm length) vegetations.
  • Echocardiography plays a major role in the identification of high-risk patients, but other biological factors may probably explain a high risk of embolism in patients with small vegetation.
  • Finally, the decision to operate early in infective endocarditis is always difficult and remains specific for the individual patient; however, this decision is clearly influenced by the presence of very large and mobile vegetation. Very recent data favour the use of early surgery when the risk of embolism is estimated very high by echocardiography.

3: Neurological complications; diagnostic and therapeutic strategies

This topic was covered by Ulrika Snygg-Martin from Sweden. Brain injuries occur in 20% to 40% of patients during the active course of infective endocarditis and are mainly the consequence of vegetation embolization or ruptured mycotic aneurysm.
The main points underlined were the following

  • Early cerebral imaging is mandatory in patients with neurological symptoms but is also frequently performed in all other patients with endocarditis.
  • Early interventional treatment may be necessary in some patients including neurosurgical treatment or neuro radiological therapy. 
  • The ESC guidelines 2009 recommend not to postpone cardiac surgery (if indicated) in case of transient ischemic attack or in case of cerebral infarction without hemorrhage or severe cerebral damage

Finally, in all these situations, a multidisciplinary approach is mandatory, including cardiologists, infectiologists, and cardiac surgeons.

References


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SessionTitle:

Difficult decisions in infective endocarditis

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.