1. Infective Endocarditis Weiyi Mai M.D. & Ph.D. Department of Cardiology, The First Affiliated Hospital, Sun Yat-sen University

3. Microbiology sx’s<60 d post op

9. Pathogenesis Pathegenesis

11. Venturi Effect

13. Microscopy

18. Clinical Features Symptoms % Signs % Fever 80-85 Fever 80-90 Chills 42-75 Murmur 80-85 Sweats 25 Changing/new murmur 10-40 Anorexia 25-55 Neurological abnormalities 30-40 Weight loss 25-35 Embolic events 20-40 malaise 25-40 Splenomegaly 15-50 dyspnia 20-40 Clubbing 10-20 Cough 25 Peripheral manifestation Stroke 13-20 Osler's nodes 7-10 Headache 15-40 Splinter hemorrhage 5-15 Nausea / vomiting 15-20 Petechiae 10-40 Myalgia / arthralgia 15-30 Janeway lesion 6-10 Chest pain 8-35 Retinal lesion/ Roth spot 4-10 Abdominal pain 5-15 Back pain 7-10 Confusion 10-20

19. AIE SIE Causative high virulence pyogenic bacteria: Staphylococcus aureus (50-80%) low virulence pyogenic bacteria: α-hemolytic streptococcus viridans (50-90%) Preexisting Cardiac abnormal usually no, Normal valves or prosthetic heart valves rheumatic valvular disease (50-60%), congenital heart disease (20%), ventricular septa defect (15%), normal valves 15%. Vegetation big, soft, friable pus-like , yellow-gray masses; white thrombus containing large amount of polymorphous neutrophils relatively firm, friable, irregular or polyp-like masses; white thrombus containing less amount of polymorphous neutrophils Valves change severe acute purulent valvulitis: the valves undergo erosion, perforation or rupture; granulation tissue is absent or scarce. mild chronic purulent valvulitis: fibrous thickening, perforation (less common), with granulation tissue in the base of the vegetation Chordae change break off very common fibrous thickened, shortened, break off less common Embolism Embolic abscesses Septicemia （ hepatomegaly, splenomegaly, hemorrhage of skin, mucosa, positive blood cultures ） Ischemic infarct (spleen, kidneys and brain)

22. Osler’s Node

24. Conjunctival Petechiae

25. Splinter Hemorrhage

26. Roth Spot

27. Clubbing

34. “ Echo should be done in all cases of suspected endocarditis.” (This is not all patients with fever or positive blood cultures). Circulation 1997; 95: 1686-1784

50. Thank you！

51. Predisposing Conditions Strom BL, Abrutyn E, Berlin JA, Kinman JL, Feldman RS, Stolley PD, et al. Ann Intern Med. 1998;129:761-9. IV drug users and nosocomial cases excluded.

53. Infection Growth of vegetation by platelet-fibrin deposition yields a sanctuary for bacteria.

54. Streptococci in IE

68. Anticoagulation “ If anticoagulation is indicated for another reason it should be continued. Anticoagulation does not prevent embolization due to IE.” ACC guidelines on Diagnosis and Management of Infective Endocarditis.

71. Bayer AS, et al. Circ 98:25, 2936-48. 22/29 Dec 98

78. Embolic Events: an Aggressive Approach Clinical Embolic Event (CNS or peripheral) CT/MR of Brain Small, ischemic infarcts & Mild neurologic impairment Vegetations present by echo Prompt Surgery Large or hemorrhagic infarct Observe Blaustein AS Card Clin 14:3,1996

81. Circulation. 96(1):358-366, 1997 July 1. Prophylaxis

89. Antibiotic Prophylaxis

90. Antibiotic Prophylaxis

91. Infective Endocarditis Questions?

92. “ The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head. Often the best part of your work will have nothing to do with potions and powders, but with the exercise of an influence of the strong upon the weak, of the righteous upon the wicked, of the wise upon the foolish.” William Osler

97. Use of Echo in Diagnosis of IE Bayer AS, et al. Circ 98:25, 2936-48. 22/29 Dec 98

99. Management of IE

100. The Sanford Guide to Antimicrobial Therapy Gilbert DN, Moellering RC, Sande MA, eds. 28th ed. 1998. Antimicrobial Therapy for IE

101. Sanford, et al.

102. Sanford, et al.

103. Sanford, et al. + gent x 14 d

104. Surgery for PVE

105. IE Prophylaxis in MVP

106. Antibiotic Prophylaxis

107. Antibiotic Prophylaxis