A 46-year-old man comes to the emergency department after awakening with dyspnea and diaphoresis this morning. He has had 6 weeks of fever, increased weakness, and fatigue. The patient underwent a root canal procedure 4 months ago but reports that he has been otherwise healthy. He has no history of cardiovascular disease, pulmonary disease, or cardiac surgery.
Temperature is 38.4 C (101.1 F), blood pressure is 144/76 mm Hg, pulse is 106/min, and respirations are 28/min. The patient is diaphoretic and appears uncomfortable. There are no skin rashes. The pupils are equal, round, and reactive without conjunctival lesions or suffusion. There is no neck stiffness or meningeal signs. A short, early diastolic murmur is heard at the left sternal border. Coarse inspiratory crackles are heard bilaterally halfway up the lung fields. The spleen is not palpable. His speech is abnormal.
Chest x-ray reveals pulmonary congestion. Transthoracic echocardiogram shows a 7-mm, mobile echodensity on the aortic valve with high-grade aortic regurgitation. MRI of the brain reveals a small area of acute infarction in the left frontal lobe.
Blood cultures are obtained and empiric antibiotics are initiated. Noninvasive positive-pressure ventilation is started with some improvement in respiratory distress.
Which of the following is an indication for cardiac valve surgery in this patient?

Question

A 46-year-old man comes to the emergency department after awakening with dyspnea and diaphoresis this morning.  He has had 6 weeks of fever, increased weakness, and fatigue.  The patient underwent a root canal procedure 4 months ago but reports that he has been otherwise healthy.  He has no history of cardiovascular disease, pulmonary disease, or cardiac surgery.
Temperature is 38.4 C (101.1 F), blood pressure is 144/76 mm Hg, pulse is 106/min, and respirations are 28/min.  The patient is diaphoretic and appears uncomfortable.  There are no skin rashes.  The pupils are equal, round, and reactive without conjunctival lesions or suffusion.  There is no neck stiffness or meningeal signs.  A short, early diastolic murmur is heard at the left sternal border.  Coarse inspiratory crackles are heard bilaterally halfway up the lung fields.  The spleen is not palpable.  His speech is abnormal.
Chest x-ray reveals pulmonary congestion.  Transthoracic echocardiogram shows a 7-mm, mobile echodensity on the aortic valve with high-grade aortic regurgitation.  MRI of the brain reveals a small area of acute infarction in the left frontal lobe.
Blood cultures are obtained and empiric antibiotics are initiated.  Noninvasive positive-pressure ventilation is started with some improvement in respiratory distress.
Which of the following is an indication for cardiac valve surgery in this patient?

Quizplus · Accepted Answer

11ec193a_9758_a84f_853d_e94f338e65ad_MD0002_00 This patient has developed subacute infective endocarditis (IE) likely due to bacteremia at the time of his recent root canal procedure. Medical management with long-term intravenous antibiotics is often successful in treating IE; however, early surgical intervention (ie, valvular repair or replacement prior to the completion of a full antibiotic course) is sometimes required. Vegetations in IE can impair valve leaflet coaptation and lead to valvular regurgitation and heart failure. Acute heart failure due to IE has a >90% mortality rate, which is reduced to 75% with medical therapy and 25% with surgical intervention. Therefore, signs of acute heart failure (eg, pulmonary edema) are a strong indication for early surgical intervention for IE. (Choice A) The location of IE alone (eg, aortic valve, mitral valve) does not indicate the need for surgery. (Choice B) This patient's brain MRI findings are consistent with an acute septic embolic stroke that occurred prior to the initiation of antibiotics. This is not an indication for valvular surgery as the risk of septic embolization usually decreases rapidly once antibiotics are initiated. However, a systemic embolic event while on appropriate antibiotics would warrant surgical intervention. (Choice C) The cardiovascular system may be able to compensate for gradually developed valvular regurgitation. Therefore, echocardiographic evidence of high-grade valvular regurgitation alone is not an indication for surgery unless it causes acute heart failure. (Choice E) Large vegetation size may increase the likelihood of septic embolization. Current guidelines recommend early surgical intervention for a mobile aortic or mitral valve vegetation >10 mm in the setting of a prior systemic embolic event. This patient's 7-mm aortic valve vegetation in the setting of a prior systemic embolic event is not an indication for early surgical intervention. Educational objective: Early surgical intervention is sometimes required in the management of infective endocarditis. Valvular regurgitation complicated by acute heart failure is a strong indication for early valvular repair or replacement. Other surgical indications include uncontrollable infection and embolic complications while on appropriate antibiotics. __________ References: Association between surgical indications, operative risk, and clinical outcome in infective endocarditis: a prospective study from the International Collaboration on Endocarditis. (http://www.ncbi.nlm.nih.gov/pubmed/25480814) Association between valvular surgery and mortality among patients with infective endocarditis complicated by heart failure. (http://www.ncbi.nlm.nih.gov/pubmed/22110106) 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. (http://www.ncbi.nlm.nih.gov/pubmed/28315732)

A 46-Year-Old Man Comes to the Emergency Department After Awakening