Education & Fellowships
Cardiothoracic Surgery Service
LAC+USC Medical Center Student Handout
- The microbiologic make-up of endocarditis varies with the geography, in NY it is E. coli, in California it is S. aureus.
- The valve most commonly affected at the LAC+USC MC is the aortic valve followed by the mitral valve. Tricuspid valves are commonly affected in IVDA patients.
- Vegetations on left sided valves will lead to embolization to the brain, from the tricuspic valve they will embolize to the lungs and present at pneumonitis.
- The left sided lesions will create hemodynamic instability, regurgitation and CHF.
Native Valve Endocarditis
- Native valve endocarditis (original valves) should be worked up with blood cultures (BC), ECHO in addition to all other modalities.
- If BC are still positive after five days of appropriate antibiotics, the patient should go to surgery.
- Streptococcus can be sterilized with antibiotics. If the valve has been destroyed or has vegetations larger than one centimeter, the patient will require surgery.
- The presence of S. aureus, coliforms or yeast demands surgery for replacement of the infected valve (one, two or three).
- If BC are negtive and the patient has no hemodynamic instability, antibiotics may be given for 4-6 weeks. If surgery is performed, the patient should receive 4-6 weeks of antibiotics AFTER surgery.
- The type of valvular prosthesis utilized in endocarditis depends on any other logic for their use since the rate of sterilization is the same for both basic types. Ideally, a total bioprosthetic like a homograft should be utilized.
- Peripheral embolization to the brain must be worked up with CAT scan. If the CVA is ischemic, surgery may be done within three days. If the infarct is hemorrhagic, surgery should be postponed for approximately three weeks. The major problem will be anticoagulation with heparin and low flow states because of CPB. In such cases, the surgery may be fatal to the patient.
- Endocarditis may produce an abscess of the skeleton of the heart and may even produce conduction disturbances if the abscess is centrally located. Fistulas between various chambers may occur with eventual CHF.
Prosthetic Valve Endocarditis
Prosthetic valve endocarditis is treated similarly as native valve disease. However, there is a tendency to replace the infected valve later as long as there is no hemodynamic instability. If by ECHO there is para-valvular leak and / or the prosthetic valve that is infected is "rocking" suggesting dehiscence, then surgery is performed ASAP. EARLY endocarditis is less than two months post-op. LATE endocarditis is beyond two months post-op.
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