Section III: Valvular Disease

HPI: Dyspnea with exertion, angina, syncope, or orthopnea. Sometimes patients adjust there lifestyle subconsciously to avoid exertion.

PMH: Hypertension, coronary artery disease, rheumatic fever/heart disease, hyperlipidemia.

PSH: Valve replacement, prior thoracotomy.

FH: Congenital bicuspid aortic valve.

SYM = SYMptomatic (See HPI).

ASYM = ASYMptomatic.

CARD-SUR = Patient is due for CARDiac SURgery for reasons other than the aortic stenosis (ex. CABG).

MOD-AS = MODerate Aortic Stenosis by echocardiography.

SEV-AS = SEVere Aortic Stenosis by echocardiography.

LVSD = Left Ventricular Systolic Dysfunction with ejection fraction < 0.50.

FOLLOW = Clinical FOLLOW up and annual echocardiogram or sooner if symptoms develop. If a patient has severe aortic stenosis very close follow up is needed and consideration should be given for exercise stress testing to objectively determine if a patient is genuinely asymptomatic.

LG-AS = Low Gradient Aortic Stenosis. If LV function is low it is possible the LV cannot generate enough pressure to reveal the true severe gradient across the aortic valve. Consider dobutamine echo to enhance LV function. If LV function improves significantly and severe aortic stenosis is seen, refer for AVR.

AVR = Refer for Aortic Valve Replacement. If patient is due for cardiac surgery for other reasons, AVR is performed at the same time to reduce perioperative risk and need for repeat thoracotomy.

MOD-AS + ASYM = FOLLOW

MOD-AS + ASYM + CARD-SUR = AVR

MOD-AS + SYM = AVR

MOD-AS + LVSD = LG-AS

SEV-AS + ASYM = FOLLOW

SEV-AS + ASYM + CARD-SUR = AVR

SEV-AS + ASYM + LVSD = AVR

SEV-AS + SYM = AVR

• – The most common cause of death in asymptomatic valve disease is surgery! Use careful consideration in determining if symptoms are genuinely present and in deciding when to time surgery.

• – 1.0–2.0% of the population born with a bicuspid aortic valve.

• – AVR is less beneficial in patients where low ejection fraction is caused by depressed contractility compared to increased afterload. Left ventricular function may be evaluated with a dobutamine echocardiogram, which will also rule out possibility of pseudo aortic stenosis.

• – Mild aortic regurgitation present in 80% of patients with AS.

1. Bonow RO, et al. ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease. J Am Coll Cardiol. 2006;48:e1–e148.

2. Carabello BA. Clinical practice: aortic stenosis. N Engl J Med. 2002;346:677–682.

HPI: Dyspnea with exertion, angina, syncope, or orthopnea.

PMH: Aortic dissection, bacterial endocarditis, hypertension, rheumatic heart disease.

SYM = SYMptomatic (See HPI).

ASYM = ASYMptomatic.

CARD-SUR = Patient is due for CARDiac SURgery for reasons other than the aortic regurgitation (ex. CABG).

MOD-AR = MODerate Aortic Regurgitation by echocardiography.

SEV-AR = SEVere Aortic Regurgitation by echocardiography.

LVSD = Left Ventricular Systolic Dysfunction with ejection fraction < 0.50.

INFXN = Infection: Severe aortic regurgitation resulting from infective endocarditis. This can be particularly devastating when the aortic regurgitation is acute. Infections often will not be successfully treated medically and resolution of the infection will not restore competency to the valve.

FOLLOW = Clinical FOLLOW up and annual echocardiogram or sooner if symptoms develop. If a patient has severe aortic regurgitation very close follow up is needed and consideration should be given for exercise stress testing to objectively determine if a patient is genuinely asymptomatic.

AVR = Refer for Aortic Valve Replacement. If patient due for cardiac surgery for other reasons, AVR is performed at the same time to reduce perioperative risk and need for repeat thoracotomy.

MOD-AR + ASYM = FOLLOW

MOD-AR + ASYM + CARD-SUR = AVR

MOD-AR + SYM = AVR

SEV-AR + ASYM = FOLLOW

SEV-AR + ASYM + CARD-SUR = AVR

SEV-AR + ASYM + LVSD = AVR

SEV-AR + INFXN = AVR

SEV-AR + SYM = AVR

• – The most common cause of death in asymptomatic valve disease is surgery! Use careful consideration in determining if symptoms are genuinely present and in deciding when to time surgery.

• – AVR is associated with a mortality rate of 4% when performed in isolation and 7% when performed with CABG.

• – Outcomes for AVR are better in patients with a left ventricular end-systolic dimension <55 mm and a left ventricular ejection fraction >55%.

1. Bonow RO, et al. ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease. J Am Coll Cardiol. 2006;48:e1–e148.

2. Enriquez-Sarano M, et al. Clinical practice. Aortic regurgitation. N Engl J Med. 2004;351:1539–1546.

3. Bekeredjian R, et al. Valvular Heart Disease: Aortic Regurgitation. Circulation. 2005;112:125–134.

HPI: Dyspnea on exertion, chest pain, atrial fibrillation, or thromboembolic event.

PMH: Rheumatic heart disease.

ECHO: Doming of anterior mitral valve (MV) leaflet, "hockey stick" appearance of anterior MV leaflet, immobility of posterior MV leaflet, MV annular calcification, thickening of MV leaflet.

X-ray: Left atrial enlargement, calcification of MV annulus, enlargement of pulmonary artery.

MS-ECHO = Moderate (mean gradient 5–10 mm Hg, pulmonary artery systolic pressure (PASP) 30–50 mm Hg, valve area 1–1.5 cm²) or severe (mean gradient >10 mm Hg, PASP >10 mm Hg, valve area <1 cm²) Mitral Stenosis on ECHOcardiogram.

PCMBV = Refer patient for PerCutaneous Mitral Valve Balloon Valvotomy.

FVM = Favorable Mitral Valve Morphology for PCMBV.

UFVM = UnFavorable Mitral Valve Morphology for PCMBV.

MVR = Refer patient for Mitral Valve Repair/Replacement.

LATH = Left Atrial THrombus.

MSMR = Moderate or Severe Mitral Regurgitation.

SYMP = SYMPtoms of dyspnea on exertion or at rest. Limitation in performing ordinary activities.

PHTN = Pulmonary hypertension (pulmonary artery systolic pressure >50 mm Hg).

ASYM = No symptoms on presentation or concomitant conditions.

MED = Yearly evaluation with history, physical exam, chest X-ray, and electrocardiogram. Yearly echocardiogram in severe mitral stenosis or patient with change in clinical.

MS-ECHO + FVM + SYMP = PCMBV

MS-ECHO + FVM + PHTN = PCMBV

MS-ECHO + UFVM = MVR

MS-ECHO + LATH = MVR

MS-ECHO + MSMR = MVR

MS-ECHO + ASYM = MED

• – PCMBV should not be performed in patients with moderate to severe mitral regurgitation (make symptoms worse) or presence of a left atrial thrombus (may embolize and form thrombus systemically).

• – In the presence of significant calcification, fibrosis, and subvalvular fusion of the MV leaflets, PCMBV is less likely to be successful, and MVR is the preferred intervention.

1. Bonow RO, et al. ACC/AHA 2008 Update of Valvular Heart Disease. J Am Coll Cardiol. 2006;48:e1–e148.

2. Carabello BA. Modern Management of Mitral Stenosis. Circulation. 2005;112:432–437.

HPI: Symptoms of dyspnea, exercise intolerance, or fatigue.

PMH: Mitral valve prolapse, coronary artery disease, rheumatic heart disease, collagen vascular disease.

ECHO: LA and LV enlargement; LV ejection fraction <0.6. Calcification of mitral annulus or leaflet.

X-ray: LA and LV enlargement, pulmonary edema, increased pulmonary vascularity.

SMR-ECHO = Severe Mitral Regurgitation on ECHO: dilated LA and LV; regurgitant volume >=60 mL/beat, regurgitant fraction >=50%, regurgitant orifice >=40 cm², abnormal flail leaflets.

MVR = Refer for Mitral Valve Repair/Replacement.

MED = Continue with patients' medical therapy and follow up with echocardiogram yearly or sooner if symptoms develop.

ASYM = No symptoms on presentation.

SYMP = SYMPtoms of dyspnea, exercise intolerance, or fatigue.

LVSD = Left ventricular ejection fraction <0.60.

ESD = End Systolic Dimension >=40 mm.

AFIB = New-onset Atrial FIBrillation (AFIB)

PHTN = Pulmonary HyperTensioN: pulmonary artery systolic pressure >50 mm Hg at rest or >60 mm Hg at exercise.

SMR-ECHO + SYMP = MVR

SMR-ECHO + LVSD = MVR

SMR-ECHO + ESD = MVR

SMR-ECHO + AFIB = MVR

SMR-ECHO + PHTN = MVR

SMR-ECHO + ASYM = MED

• – Mitral valve surgery is not indicated for asymptomatic patients with mitral regurgitation and preserved LV function, where significant doubt of feasibility of repair exists.

• – Mitral valve repair when compared to mitral valve replacement has been shown to have a lower operative mortality rate and better longer-term survival and so is preferred if feasible.

1. Bonow RO, et al. Guideline Update of Valvular Heart Disease. J Am Coll Cardiol. 2006;48:e1–e148.

2. Foster E. Mitral Regurgitation Due to Regenerative Mitral Valve Disease. N Engl J Med. 2010;363:156–165.

3. Carabello BA. The Current Therapy for Mitral Regurgitation. J Am Coll Cardiol. 2008;52:319–326.

HPI: Dyspnea on exertion, chest pain, atrial fibrillation, or thromboembolic event.

PMH: Rheumatic heart disease.

ECHO: Doming of anterior mitral valve (MV) leaflet, "hockey stick" appearance of anterior MV leaflet, immobility of posterior MV leaflet, MV annular calcification, thickening of MV leaflet.

X-ray: Left atrial enlargement, calcification of mitral valve annulus, enlargement of pulmonary artery.

PREG-MS = PREGnant patient with documented Mitral Stenosis.

SYMP = SYMPtoms of dyspnea on exertion or at rest, limitation in performing ordinary activities, orthopnea, or pulmonary edema unresponsive to medical treatment.

ASYM = Patient is ASYMptomatic.

MED = MEDical treatment with furosemide 80 mg/day and metoprolol 25 mg/day.

PCBMV = Refer patient for PerCutaneous Balloon Mitral Valvuloplasty.

SURG = Refer patient for SURGery with either mitral valve repair or replacement.

UFM = UnFavorable Mitral valve morphology for PCMBV.

PREG-MS + ASYM = MED

PREG-MS + SYMP = PCBMV

PREG-MS + SYMP + UFM = SURG

• – PCMBV should not be performed in patients with moderate to severe mitral regurgitation or presence of a left atrial thrombus.

• – Pregnant women with mitral stenosis develop symptoms most commonly in the 2nd and 3rd trimesters.

• – In patients with a favorable valve morphology PCMBV has been associated with a lower rate in fetal and neonatal mortality compared to mitral valve repair or replacement.

1. Bonow RO, et al. 2008 ACC/AHA Guideline Update on Valvular Heart Disease. J Am Coll Cardiol. 2006;48:e1–e148.

HPI: Patient presenting with palpitations, edema, and SOB.

PMH: Rheumatic heart disease, infective endocarditis, Marfan's syndrome, Ebstein's anomaly (funnel-shaped tricuspid valve).

PSH: Endomyocardial biopsy, radiation therapy.

ECHO: Dilated right atrium and right ventricle, dilated tricuspid annulus, vena contracta width >0.7 cm and systolic flow reversal in hepatic veins.

X-ray: Right atrial enlargement, prominent azygous vein, pleural effusion.

S-TR = Severe Tricuspid Regurgitation (vena contracta width >0.7 cm and systolic flow reversal in hepatic veins).

MVD = Mitral Valve Disease requiring surgery.

SYMP = Patient with SYMPtoms of dyspnea, palpitations, fatigue, or weakness.

AB-TVL = ABnormal Tricuspid Valve Leaflets not amenable to annuloplasty or repair.

MED = MEDical management with yearly echocardiogram or sooner if development of symptoms.

SURG-T = Refer patient for SURGical repair or replacement of Tricuspid valve.

S-TR = MED

S-TR + SYMP = SURG-T

S-TR + MVD = SURG-T

S-TR + AB-TVL = SURG-T

• – Operative mortality rates for patients with TR undergoing tricuspid valve repair with concomitant surgery on another valve ranged from 6–14%.

• – In patients with symptomatic TR, surgery should be performed before the development of a right ventricular end-systolic area > = 20 cm² or anemia with hemoglobin < = 11.3 g/dL as it is associated with a higher rate of event-free survival.

1. Bonow RO, et al. ACC/AHA 2008 Guideline Update on Valvular Heart Disease: Focused Update on Infective Endocarditis. J Am Coll Cardiol. 2006;48:e1–e148.

HPI: Symptoms of fever and/or new-onset murmur.

PMH: Congenital heart disease, prior infective endocarditis, mitral valve prolapse.

PSH: Mechanical heart valve.

SH: IV drug use.

Duke's Criteria

MAJOR = MAJOR criteria are:

1. two separate positive blood culture for infective endocarditis (Staphylococcus aureus, Viridans streptococci, HACEK, or Streptococcus bovis);

2. endocardial involvement (echocardiogram or new valvular regurgitation murmur).

MINOR = MINOR criteria are:

1. fever;

2. predisposition (IV drug use, cardiac condition);

3. vascular phenomena (arterial embolism, Janeway lesion, conjunctival hemorrhage, or septic pulmonary embolus);

4. immunologic phenomena (Roth spots, Osler nodes, glomerulonephritis, or rheumatoid factor);

5. microbiologic evidence (positive blood culture not meeting major criterion).

1MAJOR = Patient has 1 major Duke criteria.

2MAJOR = Patient has both major Duke criteria.

3MINOR = Patient has 3 or 4 minor Duke criteria.

5MINOR = Patient has 5 minor Duke criteria.

EC = Patient has EndoCarditis based on Duke's criteria.

2MAJOR = EC

1MAJOR + 3MINOR = EC

5MINOR = EC

• – TTE and TEE may produce false-negative results if vegetations are small or have already embolized.

• – Staphylococcus aureus is the most common cause of infective endocarditis.

1. Baddour LM, et al. Infective Endocarditis. Circulation. 2005;111: e394–e434.

2. Mylonakis E, et al. Infective Endocarditis in Adults. N Engl J Med. 2001; 345:1318–1330.

HPI: Patient with underlying cardiac condition undergoing surgery or invasive procedure.

PMH: IE, congenital heart disease (CHD), mechanical heart valve (MHV), mitral valve prolapse, rheumatic heart disease.

PSH: Valve replacement, CHD defect repair, cardiac transplant.

HIGHR = Patient with any one of the following cardiac conditions are considered at HIGH Risk for adverse outcomes from IE: MHV; previous IE; unrepaired CHD, including palliative stents and conduits; completely repaired CHD with prosthetic material or device during first 6 months following procedure; repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device; cardiac transplant recipients who develop cardiac valvulopathy.

DP = Dental Procedures involving manipulation of gingival tissue or perforation of oral mucosa.

GI/GU = GastroIntestinal or GenitoUrinary tract procedures including endoscopy, colonoscopy, cystoscopy, vaginal delivery, and hysterectomy.

RSP = ReSPiratory tract procedure involving incision of respiratory tract (biopsy, drainage of abscess, or empyema).

ISMS = surgery involving Infected Skin, skin stricture, or MusculoSkeletal tissue.

DPR = Prophylaxis for DP is amoxicillin 2 g oral or ampicillin 2 g IV if unable to tolerate oral. If allergic to penicillin give clindamycin 600 mg oral or if unable to tolerate oral give IV.

RPR = Prophylaxis for RSP is amoxicillin 2 g oral or ampicillin 2 g IV if unable to tolerate oral. If allergic to penicillin, give vancomycin 1 g oral or if unable to tolerate give IV.

IPR = Prophylaxis for ISM is amoxicillin 2 g oral or ampicillin 2 g IV if unable to tolerate oral. If allergic to penicillin, give clindamycin 600 mg oral or if unable to tolerate oral give IV.

NP = No Prophylaxis.

HIGHR + DP = DPR

HIGHR + RSP = RPR

HIGHR + ISMS = IPR

HIGHR + GI/GU = NP

• – If the dosage of antibiotic is inadvertently not administered before the procedure, the dosage may be administered up to 2 hours after the procedure.

• – Overall mortality rate for both native and prosthetic-valve endocarditis remains as high as 20–25% with death resulting from CNS embolic events and hemodynamic compromise.

1. Wilson W, et al. Prevention of Infective Endocarditis: Guidelines from the American Heart Association. Circulation. 2007;116:1736–1754.

2. Mylonakis E, et al. Infective Endocarditis in Adults. N Engl J Med. 2001;345:1318–1330.

HPI: Dyspnea on exertion, fatigue, weakness.

PMH: Congenital heart disease, prior infective endocarditis, mitral valve prolapse.

PSH: Intravenous drug use.

NVE = Patient diagnosed with Native Valve Endocarditis.

SURG = Refer patient for SURGical treatment with valve repair or replacement.

HF = Patient with Heart Failure (dyspnea on exertion or at rest, fatigue, weakness).

S-REG = Patient with Severe aortic or mitral REGurgitation with hemodynamic abnormalities such as elevated left ventricular end-diastolic pressure or premature closure of mitral valve with aortic regurgitation.

UMT-F = Endocarditis Unresponsive to Medical Treatment or due to fungal infections.

COMP = Cardiovascular COMPlications of endocarditis: heart block, perivalvular abscess, or fistula formation.

NVE + HF = SURG

NVE + S-REG = SURG

NVE + UMT-F = SURG

NVE + COMP = SURG

• – Patients with a history of intravenous drug use and human immunodeficiency virus are at increased risk for recurrent infection and reoperation.

1. Bonow RO, et al. 2008 Guideline Update of Valvular Heart Disease. J Am Coll Cardiol. 2006;48:e1.

2. Fedoruk LM, et al. Predictors of Recurrence and Reoperation for Prosthetic Valve Endocarditis after Valve Replacement Surgery for Native Valve Endocarditis. Thorac Cardiovasc Surg. 2009;137:326–333.

HPI: Symptoms of fever and/or new-onset murmur.

PMH: Congenital heart disease, prior infective endocarditis, mitral valve prolapse.

PSH: Heart valve replacement.

SH: IV drug use.

PVIE = Patient with Prosthetic Valve Infective Endocarditis.

STREP = 2 positive blood cultures for Viridans STREPtococci or Streptococcus bovis.

STAPH = 2 positive blood cultures for STAPHylococcus aureus.

ENTRC = 2 positive blood cultures for ENTeRococci.

HACEK = 2 positive blood cultures for HACEK organisms (Haemophilus aphrophilus, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, or Kingella kingae).

CNEG = Culture NEGative endocarditis (endocarditis without etiology following inoculation of 3 blood samples in a standard blood culture system).

ABL = Patient Allergic to Beta-Lactam antibiotics.

CTX-6 = Ceftriaxone 2 g/24 hr IV for 6 weeks.

CTX-4 = Ceftriaxone 2 g/24 hr IV for 4 weeks.

GENT-2 = GENTamycin 3 mg/kg per 24 hours IV in 3 equally divided doses for 2 weeks.

GENT-6 = GENTamycin 3 mg/kg per 24 hours IV in 3 equally divided doses for 6 weeks.

NAF = NAFcillin 12 g/24 hr IV in 6 equally divided doses for 6 weeks.

RIF = RIFampin 900 mg/24 hr IV in 3 equally divided doses for 6 weeks.

AMP = AMPicillin-sulbactam 12 grams per 24 hours IV in 4 equally divided doses for 4 weeks.

VANC = VANComycin 30 mg/kg per 24 hours IV in 2 equally divided doses for 6 weeks.

CIPRO = CIPROfloxacin 800 mg/24 hours IV in 2 equally divided doses for 4 weeks.

PVIE + STREP = CTX-6 + GECT

PVIE + STAPH = NAF + RIF + GENT

PVIE + ENTRC = AMP

PVIE + HACEK = CTX-4

PVIE + STREP + ABL = VANC

PVIE + STREP + ABL = VANC + RIF + GENT

PVIE + ENTRC + ABL = VANC + GENT-6

PVIE + HACEK + ABL = CIPRO

– Endocarditis caused by Staphylococcus aureus is associated with a lower mortality rate than streptococcal infection.

– The risk of embolization is decreased after the institution of effective antimicrobial therapy in patients with infective endocarditis.

1. Baddour LM, et al. Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America. Circulation. 2005;111:e394–e434.

HPI: Dyspnea on exertion, fatigue, weakness.

PMH: Congenital heart disease, prior infective endocarditis, mitral valve prolapse.

PSH: Prosthetic valve replacement.

SH: Intravenous drug use.

PVE = Patient diagnosed with Prosthetic Valve Endocarditis.

SURG = Refer patient for SURGical treatment with valve repair or replacement.

HF = Patient with Heart Failure (dyspnea on exertion or at rest, fatigue, weakness).

REG = Patient with increasing valve obstruction or worsening REGurgitation.

UMT-F = Endocarditis Unresponsive to Medical Treatment or due to Fungal infections.

COMP = COMPlications of endocarditis such as heart block, perivalvular abscess, or fistula formation.

PVE + HF = SURG

PVE + REG = SURG

PVE + UMT-F = SURG

PVE + COMP = SURG

– Patients with a history of intravenous drug use and human immunodeficiency virus are at increased risk for recurrent infection and reoperation.

– Long-term mortality is increased in patients who develop PVE within 6 months of surgery.

1. Bonow RO, et al. ACC/AHA 2008 Guideline Update on Valvular Heart Disease: Focused Update on Infective Endocarditis. J Am Coll Cardiol. 2008;118:887–896.

HPI: Symptoms of fever and/or new onset murmur.

PMH: Congenital heart disease, prior infective endocarditis, mitral valve prolapse.

PSH: Mechanical heart valve.

SH: IV drug use.

NVIE = Patient with Native Valve Infective Endocarditis.

STREP = 2 positive blood cultures for Viridans streptococci or Streptococcus bovis.

STAPH = 2 positive blood cultures for Staphylococcus aureus.

ENTR = 2 positive blood cultures for enterococci.

HACEK = 2 positive blood cultures for HACEK organisms (Haemophilus aphrophilus, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, or Kingella kingae).

CXNEG = Culture negative endocarditis (endocarditis without etiology following inoculation of 3 blood samples in a standard blood culture system).

CTX-GENT = Ceftriaxone 2 g/24 hr IV and Gentamycin 3 mg/kg per 24 hours IV for 2 weeks.

NAF-GENT = Nafcillin 12 g/24hr IV in 6 equally divided doses for 6 weeks and Gentamycin 3 mg/kg per 24 hours IV in 3 equally divided doses for 3 days.

AS-GENT = Ampicillin-sulbactam 12 grams per 24 hours IV in 4 equally divided doses for 4 weeks and Gentamycin 3 mg/kg per 24 hours IV in 3 equally divided doses for 4 weeks.

AMP = Ampicillin 12 g/24 hr IV in 6 equally divided doses, for 4 weeks.

CEF = Ceftriaxone 2 g/24 hr IV for 4 weeks.

NVIE + STREP = CTX-GENT

NVIE + STAPH = NAF-GENT

NVIE + ENTRC = AMP

NVIE + HACEK = CEF

NVIE + CXNEG = AS-GENT

• – For patients with IE and STREP who cannot tolerate beta-lactam antibiotics, give vancomycin 30 mg/kg per 24 hours IV in 2 equally divided doses for 4 weeks.

• – For patients with IE and STAPH who cannot tolerate beta-lactam antibiotics, give vancomycin 30 mg/kg per 24 hours IV in 2 equally divided doses for 6 weeks.

• – For patients with IE and ENTRC who cannot tolerate beta-lactam antibiotics, give vancomycin 30 mg/kg per 24 hours IV in 2 equally divided doses and gentamycin 3 mg/kg per 24 hours IV in 3 equally divided doses for 6 weeks.

• – For patients with IE and HACEK who cannot tolerate beta-lactam antibiotics, give ciprofloxacin 800 mg/24 hours IV in 2 equally divided doses.

• – For patients with IE and CXNEG, give ciprofloxacin 800 mg/24 hours IV in 2 equally divided doses.

• – Endocarditis caused Staphylococcus aureus is associated with a lower mortality rate than streptococcal infection.

• – The risk of embolization is decreased after the institution of effective antimicrobial therapy in patients with infective endocarditis.

1. Baddour LM. Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management Complications Circulation. 2005;111:e394–e434.

Systemic symptoms: Fever, chills, malaise, anorexia, nausea, sweating symptomatic heart failure.

Pacemaker site: Pocket infection: local signs of inflammation at the generator pocket, including swelling, erythema, warmth, tenderness, drainage, purulent drainage, skin ulceration, and generator/lead erosion

TEE-vegetations can occur anywhere along the course of the electrode, including the endocardium of the right atrium or right ventricle.

CXR for pneumonia, empyema, lung abscess.

INPM = INfected PaceMaker.

PPBC = Persistent Positive Blood Culture (patients with persistently positive blood cultures should be treated for at least 4 weeks with antimicrobials even if TEE is negative for vegetations or other evidence of infection).

T4W = Treatment for at least 4 Weeks.

DR = Device Removal (device and leads removed, regardless of clinical presentation).

Indications for device removal:

1. If there is clinical or echocardiographic evidence of pacemaker/AICD infection.

2. If there is no other source identified for SAB.

3. If there is relapsing SAB after a course of appropriate antibiotic therapy.

AMT = Antimicrobial Therapy.

GS-BCX = Gram stain and culture and lead tip culture should be obtained. All patients should have at least two sets of blood cultures drawn at initial evaluation. Document negative cultures. Blood cultures should be repeated in all patients after device removal.

PNI = Pacemaker Not Infected.

SD = Salvage Device: patients with bacteremia from a defined source other than the device (including valvular infection) if the following conditions are met: no clinical/TEE evidence of lead infection; no evidence of pocket infection; and device has not been manipulated. Treated with antibiotics for the bacteremic disease and then observed for relapse. Subsequent unexplained relapse suggests device infection and a need to extract the system.

INPM = DR + GS-BCX + AMT

PPBC = T4W + AMT

PNI = SD + AMT

When to call an Infectious Diseases Consultation:

1. Patients with negative blood cultures and recent prior antibiotics and valve vegetations on TEE should be managed in consultation with an infectious diseases expert.

2. If an infected cardiac device cannot be removed, then long-term suppressive antibiotic therapy should be administered after completing an initial course of treatment and securing a clinical response to therapy.

Assess need for reimplantation: reevaluation for continued need of the device should be performed before new device placement.

Timing of reimplantation: adequate debridement and control of infection should be achieved at all sites before reimplantation of a new device.

Skin flora that grows in culture from percutaneous aspirates of fluid or abscess collection should be considered as pathogens. Unlike infective endocarditis, fastidious and uncommon microorganisms that do not grow or stain positive by routinely used laboratory methods have not been identified as pathogens in pacemaker infections.

Warning: risk of PE during device extraction from the vegetations.

1. Sohail MR, et al. Management and Outcome of Permanent Pacemaker and Implantable Cardioverter-Defibrillator Infections. J Am Coll Cardiol. 2007;49;1851–1859.

2. Baddour LM, et al. Nonvalvular Cardiovascular Device–Related Infections. Circulation. 2003;108;2015–2031.