‫كلية الطب والجراحة‬

Tricuspid Valve Disease and Infective

endocarditis

Updated by: dr. Adel Shabana

Tricuspid
Valve
disease
 Tricuspid regurgitation
 Causes:
 It is usually ‘secondary’ as a result of RV or RA dilatation (commonly
from left sided heart disease)
 Other causes include rheumatic fever, congenital diseases, carcinoid,
infective endocarditis (IV drug users) and Iatrogenic causes
(cardiac device implantation with a leadwire crossing through the valve).

 Pathophysiology: volume overload of the RV, leading to right

heart failure.
Clinically:
 Systemic venous congestion, including elevated JVP with giant V wave,
pulsatile enlarged liver, ascites and peripheral oedema
 Pansystolic murmur heard at the left sternal edge that is loudest in
inspiration (Carvallo sign) and associated with an RV heave.
Echocardiography is diagnostic
Management
Treatthe cause
Diuretics
Surgery
 Tricuspid stenosis
 Main cause: rheumatic fever, and it is almost always accompanied by mitral valve
disease.
 Pathophysiology: pressure overload of the RA, raising RA pressure to produce
symptoms of right heart failure.
 JVP is elevated with giant A waves.
 Local Examination reveals a mid-diastolic murmur, which is low in pitch and heard at
the lower left sternal edge, loudest in inspiration.
 Main treatment is by diuretics, while valve replacement may be needed in
symptomatic severe disease or those undergoing left sided valve surgery.
Infective endocarditis
LEARNING OBJECTIVES
• List the causes and presentation of acute and subacute infective endocarditis
• Recognize the microorganisms responsible for infective endocarditis
• Identify the risk of predisposing conditions for infective endocarditis
• Evaluate the methods of diagnosing infective endocarditis
• Identify the basis of treatment of endocarditis and indication for surgery
• Recognize the conditions that require prophylaxis for infective endocarditis
 Definition:
“Inflammation of the endocardial surface of the heart (endocardium, the inner
lining of the heart chambers and valves, )” in which the heart valves are colonized
with microbial organisms, causing friable infected vegetations and valve injury.
Bacterial endocarditis produces large vegetations and may affect any valve in
the heart, although left -sided lesions of the aortic and mitral valves are more
common.
The bacteremia can be induced by dental procedures, venous catheters, UTI
and other infections, or IV drug users.
MORTALITY STILL HIGH “20-30%”
N.B. Non-infective endocarditis: as rheumatic fever or collagen diseases
Classification
1. Acute infective endocarditis:
o It is usually caused by virulent bacteremia that may seed even in previously normal
valves, leading to large, bulky vegetations
o Staph. aureus is the most common cause.
o Rapid onset with fever and sometimes sepsis
o IV drug use is a major risk factor (usually affecting tricuspid valve)
o Associated with big vegetations, invasion of myocardium (abscess cavities) and rapid
valve destruction
o Embolic complications may occur
o Treatment is intensive antibiotics and usually surgery is needed
2. Subacute infective endocarditis:
o It is less fatal than acute endocarditis, associated with low virulence.
o It is commonly caused by viridans group streptococci.
o The microbes commonly seed previously abnormal valves, producing smaller
vegetations composed of fibrin, platelets, debris, and bacteria
o Slow onset with vague symptoms, leading to malaise, low-grade fever, weight loss,
and flu-like symptoms.
o Risk factors (in the heart) include valve diseases (especially rheumatic), congenital
diseases especially ventricular septal defects and prosthetic valve.
o Destruction of valves is a usual sequalae and may need surgical correction.
Microorganisms Responsible for Infective Endocarditis

 The most likely organisms for native valve endocarditis (NVE) are
streptococcus viridians (more than half the cases) followed by
staphylococcus aureus and other streptococci. Other bacteria include
staphylococcus epidermidis, gram negative bacilli, enterococci and
atypical bacteria. However, in IV addicts, most cases are caused by
staphylococcal infections.
 Prosthetic valve endocarditis (PVE) is mostly caused by staphylococcus
epidermidis in the first few months postoperatively, but late infections
are similar to native valves.
Complications: caused by emboli, local spread of
infection, metastatic spread and immune complexes e.g.

1. CHF (most common cause of death)

2. Septic embolization (related to infarctions and metastatic infections):
brain (“mycotic” aneurysm); spleen (greater with subacute); kidneys;
coronary arteries. Right sided endocarditis can cause pulmonary abscesses
3. Vasculitis
4. Glomerulonephritis with nephrotic syndrome or renal failure (immune
complex)
5. Cardiac extension of infection  abscess (aortic root abscess may be
Clinical picture:
general:

1- Fever which may be continuous, and usually of low grade.

2- Deterioration of general condition, anorexia and weakness.

3- The spleen is enlarged and tender in 80% of cases.

3- Symptoms/signs of complications as blindness or loin pains.

 Peripheral manifestations:
• Petechiae: red, non-blanching lesions on conjunctivae, buccal mucosa,
palate, extremities
• Splinter hemorrhages: linear, red brown streaks, usually proximal in
nailbeds
• Osler’s nodes: 2–5 mm painful nodules on pads of fingers or toes
• Janeway lesions (10–15%): macular, red, or hemorrhagic, painless patches
on palms or soles
• Roth’s spots (<5%): oval, pale, retinal lesions surrounded by
hemorrhage
Locally…………..

 New murmurs
 Heart failure
Investigations:
I. Lab investigations:
1. Several blood cultures (complete aseptic conditions, different sites).
2. There is a marked elevation in E.S.R. & C.R.P.
3. Anemia & leucocytosis.
4. Microscopic or macroscopic hematuria.
II. Echocardiography:
To detect vegetations in 80% of cases.
 Diagnosis of IE is done through modified Duke’s criteria.
 Definite diagnosis includes major and minor criteria.
 The 2 major criteria are: Positive blood cultures with typical
organisms and echocardiographic evidence of endocardial
involvement.
 The
minor criteria include: fever, predisposing factors, vascular,
embolic or immunologic phenomena.
Note:
• Look for colon cancer in patients with Streptococcus bovis
endocarditis.
• Coxiella burnetii can cause culture-negative endocarditis. Think of
this in patients exposed to animals, such as farmers or zoo keepers. A
Single positive blood culture for Coxiella burnetiid is enough for
diagnosis
Treatment:
Points to be considered:

1. Any obscure fever more than a few days in a

predisposed person should be considered IE until
proved otherwise
2. Start antibiotic therapy (empirical) after withdrawal
of the blood cultures (do not wait for the results).
3. Antibiotic therapy usually combinations and
parentral, at least for 6 weeks to avoid relapse.
Pharmacological treatment:

The initial choice of empirical treatment depends on several

considerations:
(1) Whether the patient has received previous antibiotic therapy.
(2) Whether the infection affects a native valve or a prosthesis [early vs. late PVE].
(3) The place of the infection (e.g. community, or nosocomial)

Thus, NVE and late PVE regimens should cover staphylococci, streptococci, and
enterococci. Early PVE or healthcare-associated IE regimens should cover
methicillin- resistant staphylococci (MRSA) and enterococci. Once the pathogen
is identified (usually within 48 h), the antibiotic treatment must be adapted to
its antimicrobial susceptibility pattern.
e.g. of empirical regimens:

For NVE or late PVE (≥12 months post-surgery) endocarditis:

- Ampicillin (12 g/day i.v. in 4–6 doses) + (Flu)cloxacillin or oxacillin (12
g/day i.v. in 4–6 doses) + Gentamicin (3 mg/kg/day i.v. or i.m. in 1 dose)
- In case of penicillin allergy  Vancomycin (30–60 mg/kg/day i.v. in 2–3
doses) + Gentamicin (3 mg/kg/day i.v. or i.m. in 1 dose)
‫مش مهم الجرعات‬
For Early PVE (<12 months post-surgery): Vancomycin + Gentamycin as
above, usually with Rifampicin (oral)
Surgical Treatment:
 In some cases, surgery needs to be performed on an emergency (within 24 h) or urgent
(within a few days - 7 days) basis, irrespective of the duration of antibiotic treatment.
 In other cases, surgery can be postponed allowing 1 or 2 weeks of antibiotic treatment
under careful clinical and echocardiographic observation before an elective surgical
procedure is performed.
 The main indications for surgery are:
1. Heart Failure: e.g. due to severe mitral or aortic regurge
2. Uncontrolled infection e.g. Persistent bacteremia despite adequate antibiotic therapy
or local complication (e.g. aortic root abscess)
3. Prevention of embolic events (e.g. large vegetation and Recurrent systemic emboli).
4. Prosthetic valve endocarditis usually needs replacement of infected prosthesis.
 N.B.Long PR interval in ECG may be a clue to search
for Aortic Root abscess especially in patients with
persistent fever despite adequate antibiotics
High risk
Prophylaxis Groups:
against IE:
Congenital heart defects e.g cyanotic D..
1.valvular lesions no longer need prophylaxis, even for dental procedures except if there is history of previous endocarditis.
Native
Prophylaxis with medications is now indicated only when there is both (1) a serious underlying cardiac defect and (2) a procedure
Prosthetic valves
2.bacteremia, because in these cases IE is expected to be severe and complicated.
causing

3. Previous endocarditis

Procedure with high risk bacteremia  Dental procedures

Amoxicillin or ampicillin 2 gm orally or IV single dose 30-60 min. before procedure If there
is penicillin allergy, replace by Clindamycin 600 mg orally or IV