This document provides information on heart anatomy, physiology, and major heart diseases. It focuses on infective endocarditis - an infection of the heart valves. Key points include: infective endocarditis is commonly caused by bacteria entering the bloodstream from procedures like dental work; common symptoms are fever and heart murmur; diagnosis involves blood cultures and echocardiogram; treatment involves antibiotics based on culture results and may require surgery for complications. Prognosis depends on preventing complications through appropriate treatment.

3. Heart - Anatomy

4. Heart Valves

5. Coronary Circulation

7. Histology

8. Major Groups Of Heart Diseases
 Congenital Heart diseases
 Valvular Heart Diseases
 Ischemic Heart Disease
 Cardiomyopathies

9. Major Vessels

10. Heart- Physiology

11. Heart -Electrical System

12. Nerves Supplying Heart

13. Heart Sounds
 Produced on CLOSURE of valves
 S1 ( mitral and tricuspid valves)
 S2 (aortic and pulmonary valves)

14.  There is a silent gap between S1 and S2 and then between S2 and S1

15. Murmurs

16. Guess which valve has malfunctioned

17. You can guess – If you know Cardiac
Cycle events

18. Site of Origin Of Murmur- clinical points
to be noted
 Area of heart
 Radiation of Sound
 Timing of murmur
 Systolic
 Diastolic
 Continuous
 Relationship with respiration
 Increases with inspiration
 Increases during expiration

19. How to Time Murmurs
 Timing is with carotid impulse

20. Case History
 A 24 year male came with history of high grade fever with for 5 days. Two
weeks back he had had a dental extraction at local clinic. His previous
history included some cardiac disease for which record was not available.
On examination he was running 103 F temperature. The pulse was 110/
min and irregular. The apex beat was heaving in character and a
pansystolic murmur radiating to left axilla was present.
 What is the diagnosis?

21. Case History
A 24 year male came with history of high
grade fever with for 5 days. Two weeks back
he had had a dental extraction at local clinic.
His previous history included some cardiac
disease for which record was not available.
On examination he was running 103 F
temperature. The pulse was 110/ min and
irregular. The apex beat was heaving in
character and a pansystolic murmur radiating
to left axilla was present.
What is the diagnosis?

22. Diagnosis
Fever and Murmur ----- ALWAYS
think of
 Infective Endocarditis

23. Definition
 Infective endocarditis is defined as
an infection of the endocardial
surface of the heart which may
include
– one or more heart valves
– the endocardium
– septal defect

24. Important Targets
 IE develops most commonly on the
mitral valve, followed by the aortic
valve
 Mechanical prosthetic valve
 Bioprosthetic valves

25. Mitral Valve

26. Pathogenesis
All cases of IE develop from a
commonly shared process
 Bacteremia
 Adherence of the organisms
 Invasion of the valvular laeflets

27.  Pre-existing thrombus at injury site
 Bacterial colonization over this
thrombus
 Resulting mass is called a Vegetation

28. Vegetation Histopathology

29. In acute IE, the thrombus may be
produced by the
 invading organism ( S aureus)
 valvular trauma from medical
devices
 S aureus can invade directly

30. Nonbacterial thrombotic endocarditis
may result from
 Stress
 Systemic lupus erythematosus
 Neoplasia

31.  The microorganisms that most commonly produce
endocarditis
 S aureus
 Streptococcus viridans
 Group A, C, and G streptococci
 Enterococci
 These resist the bactericidal action of complement
 Possess fibronectin receptors for the surface of the fibrin-
platelet thrombus.

32. Sources Of Bacteremia
Bacteremia can result from various
invasive procedures
● oral surgery
● sclerotherapy of esophageal varices
● genitourinary surgeries
● abdominal operations

33. Types Of Endocarditis
 Native Valve Endocarditis
Rheumatic Valve
Mitral Valve Prolapse
Congenital
Degenerative
 Prosthetic Valve Endocarditis
 IV drug user endocarditis
 Nosocomial
 Fungal

34. Prosthetic Valve Endocarditis

35. Clinical Features
 Symptoms - vague
 Fever and chills are the most common symptoms
 Anorexia, weight loss, malaise,
 headache, myalgias, night sweats
 shortness of breath
 cough
 joint pains

36.  Primary cardiac disease
 may present with signs of congestive heart failure
 Secondary phenomena
 include
 focal neurologic complaints
 Back pain associated with vertebral osteomyelitis

37.  Dyspnea, cough, and chest pain are
common complaints of intravenous
drug users
 Secondary embolism in lung

38. Subacute Vs Acute IE
 key concern is the distinction between
subacute and acute IE.
 The diagnosis of subacute IE is suggested by a
history of a gradual onset process
 Cerebrovascular accident
 Congestive heart failure- gradual onset

39. CT Scan Brain

40. Subactue IE cont'd
 The patient should be questioned about
invasive procedures and recreational drug use
that may be causing the bacteremia.
 Most subacute disease caused by S viridans
infection is related to dental disease.
 Most cases are not caused by dental procedures
but by transient bacteremias secondary to
gingivitis.
 In 85% of patients, symptoms of endocarditis
appear within 2 weeks of dental or other
procedures.

41. ● Early subacute native valve endocarditis
(NVE) symptoms are usually subtle and
nonspecific. They include low-grade fever
anorexia, weight loss, influenzalike
syndromes, polymyalgia-like syndromes,
pleuritic pain
● When appropriate therapy is delayed for
weeks or months, additional clinical
features, embolic or immunological in
origin, develop.

42. Acute IE
 Acute IE is an aggressive disease.
 Acute onset of high-grade fevers
and chills
 Rapid onset of congestive heart
failure
 History of antecedent procedures or
illicit drug use

43. Physical Sign
 Petechiae - Common but nonspecific finding
 Subungual (splinter) hemorrhages
 Osler nodes - Tender subcutaneous nodules
usually found on the distal pads of the digits
 Janeway lesions – Non-tender maculae on the
palms and soles
 Roth spots - hemorrhages with small, clear
centers

44. Splinter Hemorrhage

45. Janeway Lesion

46. Clubbing

47. Roth Spots in Fundus

48. Acute IE Cont'd
 Murmurs
 Aortic regurgitation murmur
 Fever is always present

49. Complications
 Myocardial infarction, pericarditis, cardiac arrhythmia
 Cardiac valvular insufficiency
 Congestive heart failure
 Sinus of Valsalva aneurysm
 Aortic root or myocardial abscesses
 Arterial emboli, infarcts, mycotic aneurysms
 Arthritis, myositis
 Glomerulonephritis, acute renal failure

50. Dukes Crieteria
 Two blood cultures positive for organisms
typically found in patients with IE (ie, S viridans,
Streptococcus bovis, a HACEK group organism,
community-acquired S aureus, or enterococci in the
absence of a primary focus)
 Blood cultures persistently positive for one of the
above organisms from cultures drawn more than
12 hours apart
 Three or more separate blood cultures drawn at
least 1 hour apart

51. Echocardiogrpahic Criteria
● Echocardiogram positive for IE, documented
by an oscillating intracardiac mass on a valve or
on supporting structures
● Myocardial abscess
● Development of partial dehiscence of a
prosthetic valve
● New-onset valvular regurgitation

53. Echocardiography

54. Normal Heart On Echocardiography

55. Tricuspid Vegetation

56. Mitral Regurgitation On Echocardiography

57. Investigations
 CBC ESR
 Urine CE
 CXR
 Echocardiography
 Blood Cultures

58. Most Important
Investigation in IE is ..
Blood Culture /
Sensitivity

59. Normal CXR

60. Cardiomegaly

61. Pleural Effusion

62.  Atrial Myxoma
Differential Diagnoses

63. Treatment
 The major goals of therapy for infective endocarditis (IE) are to eradicate
the infectious agent from the thrombus
 To Treat the complications of valvular infection including extracardiac
complications
 Some of the effects of IE require surgical intervention.

64. Empiric Therapy
● It is chosen based on the most likely infecting
organisms.
● Native valve endocarditis (NVE) has often been
treated with penicillin G and gentamicin for
synergistic coverage of streptococci.
● Patients with a history of intravenous (IV) drug
use have been treated with nafcillin and
gentamicin to cover for methicillin-sensitive
staphylococci.
● Vancomycin

65. Prophylaxis
 Consider prophylaxis against IE in
patients at higher risk.
 Presence of prosthetic heart valve
 History of endocarditis
 Congenital heart disease with a high-
pressure
gradient lesion

66. Prognosis
 Prognosis largely depends on whether or not complications
develop. If left untreated, IE is generally fatal.
 Cure rates for appropriately managed NVE
● For S viridans and S bovis infection, the rate is 98%.
● For enterococci and S aureus infection in individuals who abuse
intravenous drugs, the rate is 90%.
● For community-acquired S aureus infection in individuals who do
not abuse intravenous drugs, the rate is 60-70%.
● For infection with aerobic gram-negative organisms, the rate is
40-60%.
● For infection with fungal organisms, the rate is lower than 50%.

67. Always Remember to auscultate heart of
a patient for cardiac murmur before
performing any dental procedure

68. Thank You