Infective Endocarditis: An Old But Changing Disease

Main Category: Cardiovascular / Cardiology
Also Included In: Heart Disease
Article Date: 02 Sep 2009 - 0:00 PDT

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Infective endocarditis (IE) is a severe form of valve disease characterized by infection located in the valves of the heart. It is still associated with a high mortality (10-26% in-hospital mortality). IE is a rare disease, with reported incidences ranging from 3 to 10 episodes/100,000 people per year.

Previous guidelines were published in 2004. Current revision was needed because of changes in the epidemiological profile, and significant advances in diagnostic and therapeutic strategies in these patients. The new guidelines will serve as a guide to help physicians to choose the best diagnostic and therapeutic strategy for their patients.

Two important points to underline:

1. A multidisciplinary approach is mandatory for the treatment of patients with infective endocarditis, including cardiologists, cardiac surgeons, and specialists of infectious diseases. They must be treated in highly specialized centers with surgical facilities. A recent work from our center showed that this multidisciplinary approach was responsible for a dramatic reduction in mortality in IE.
   
   
2. A second important conclusion of our study- reflected in the current guidelines- is that surgery must be performed much earlier than initially proposed, with good results. This point will be outlined by the current guidelines, which, for the first time, give information about optimal timing of surgery in patients with IE.

The main news in the current guidelines is:

• a. Epidemiology of endocarditis is changing:
  From an epidemiological point of view, IE has changed over the last few years, with newer predisposing factors - valve prostheses, degenerative valve sclerosis, intravenous drug abuse (IVDA), associated with the increased use of invasive procedures at risk for bacteremia, while rheumatic disease has nearly disappeared. Health care-associated IE (meaning IE caused by in-hospital contamination) represents up to 30% cases of IE, justifying aseptic measures during venous catheters manipulation and during any invasive procedures
  
  
• b. Endocarditis prophylaxis is reduced: favor PREVENTION rather than PROPHYLAXIS
  One of the main changes in the new ESC Guidelines is the proposed reduction of prophylaxis, because there is no real scientific proof of its efficacy, and it may be potentially dangerous. Thus, antibiotic prophylaxis is now recommended only for patients with the highest risk of IE undergoing the highest risk dental procedures (slide). Good oral hygiene and regular dental review have a very important role in reducing the risk of IE.
  
  
• c. Echocardiography is the key of diagnosis, prognosis, and management of patients with endocarditis
  Diagnosis of IE is frequently difficult, particularly in some subgroups (prosthetic valve IE [PVE], intracardiac device and blood-culture negative IE [BCNIE]). The key value of echocardiography is underlined (slide), as well as its value in predicting embolic events
  
  
• d. Half patients with IE are operated on in Europe
  The treatment of IE relies on the combination of prolonged antimicrobial therapy and - in about half patients - surgical eradication of the infected tissues. The 3 main complications of IE indicating early surgery are heart failure (HF), uncontrolled infection, and prevention of embolic events. The new guidelines will focus on these 3 main indications
  
  
• e. Early surgery is safe and is recommended
  One of the most controversial issues is the indication of surgery. It is very difficult to say in which case and at which time surgery must be performed. Particularly, the risk of embolism is very difficult to assess. The new guidelines will focus for the first time on the optimal timing of surgery.

Source:
Jacquelline Partarrieu
European Society of Cardiology

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