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Improving the quality of life and reducing sudden cardiac death by limiting the impact of heart rhythm disturbances.
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INFECTIVE ENDOCARDITIS (IE) is a deadly disease. Despite improvement in early diagnosis and management, IE remains associated with high mortality and severe complications. After the 2009 ESC guidelines these updated guidelines on IE takes account of new publications - including the first randomised study of surgical treatment and the important improvement of imaging (especially nuclear imaging).
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The guidelines focus on prophylaxis, a new concept of ‘reference centre and endocarditis team’, the role of TEE and TOE, the new Duke criteria and a very detailed update on antibiotic treatment. They provide the clinician with an evidence-based scoring system based on a classification of the strength of recommendations and the level of evidence. And as a new feature after each section there is a concise summary of what aspects have been reviewed.
As in the previous guidelines on IE, prophylaxis is considered only for the highest risk patients when a highrisk procedure is performed. At the same time non-specific prevention measures are advised in high-risk and intermediate risk patients.
After long discussions among the task force, a very practical algorithm has been proposed for the patient with known or suspected for IE.
One of the most important parts of the new guidelines is the concept of a reference centre and endocarditis team. Thus, the guidelines state: ‘Patients should be evaluated and managed at an early stage in a reference centre, with immediate surgical facilities and the presence of a multidisciplinary team, the ‘Endocarditis Team’. This should include a cardiologist an infectious disease specialist, a microbiologist, imaging specialist, a cardiac surgeon, and, if needed, a specialist in CAD.
The cornerstone of diagnostic criteria for IE remains the modified Duke criteria, which are categorised in ‘Definite’, ‘Possible’ and ‘Rejected’ IE. The task force proposed the addition of a further two major imaging criteria: the detection of paravalvular lesions by cardiac CT and ‘an abnormal activity around the site of a prosthetic valve detected by 18F-FDG PET/CT or radiolabelled leucocyte SPECT/ CT’, with the detection of embolic events/vascular phenomena detected by imaging alone a minor criteria. A clear catalogue of anatomical and echocardiographic definitions of what constitutes a vegetation, abscess, pseudoaneurysm, perforation, fistula, valve aneurysm, and dehiscence of a prosthetic valve has been agreed to facilitate communication among experts.
What has not changed is the recommendation to limit antibiotic prophylaxis to patients at high risk of IE having dental procedures, and the guidelines provide detailed information on antibiotic treatment for every type of organism and situation.
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