Teaching Handout – Cardiology 2
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Essential in black. Optional in grey
Complications of prosthetic
valves
1. Infection – endocarditis and septic embolic phenomena
2. Valve thrombosis and blockage
3. Valve failure and regurgitation/paravalvular leak
4. Haemolysis
5. Bleeding events from anticoagulation
6. Thromboembolic phenomena
Medical Management of
prosthetic valves
1. Anticoagulation
2. Antimicrobial prophylaxis during high risk procedures
3. Yearly clinic follow up with echocardiogram
Signs of I/E
1. Systemic: Fever, anorexia, weight loss, night sweats
2. Cardiac: Valvular incompetency and murmur, heart failure, aortic root abscess
3. Septic emboli - cutaneous, pulmonary, cerebral, spleen, liver abscesses
4. Splinter haemorrhages, Osler nodes, (painful) Janeway Lesions (painless) , Clubbing, Roth Spots
Petechial rash
5. Glomerulonephritis
Dukes Criteria for diagnosis (Know there is a Duke’s Criteria, you don’t need to memorise it!)
2 major / 1 major 3 minor / 5 minor
Major:
1. Positive blood culture (2x typical organisms or persistent)
2. Positive Echo (vegetation, abscess, valve dehiscence)
Minor:
1. Predisposition (valvular lesion or IVDU)
2. Fever
3. Peripheral stigmata
4. Positive blood cultures not fulfilling major criteria
5. Echo suspicious but not fulfilling major criteria (eg new regurgitation)
Organisms in I/E
Native valve non IVDU:
1. Strep viridans
2. Strep. bovis (more common than viridans in >60yr, association with bowel cancer)
3. Staph aureus (acute and fulminant endocarditis)
4. Enterococcus
Native valve IVDU:
1. Staph aureus
2. Strep viridans
3. Candida
Prosthetic valve <60 days post surgery:
1. Staph epidermidis (coag-negative staph)
2. Staph aureus
Prosthetic valve >60 days - as per native valve
HACEKs: gram negatives, oropharyngeal flora, rare cause of culture negative endocarditis:
Haemophilus
Aggegatibacter
Cardiobacterium hominis
Eikenella
Kingella
Antibiotic Prophylaxis
Antibiotic prophylaxis should be considered prior to invasive procedures in patients with valvular or
endocardial lesions or prosthetic valves, and the decision made based on the particular cardiac condition,
the procedure and the patient.
2007 American Heart Association guidelines – antibiotics should only be used based on risk assessment
WRT cardiac condition and procedure undertaken.ie:
High risk cardiac lesion + High risk procedure – give antibiotics
1 high risk, other low risk – probably give antibiotics
Both low risk – do not give antibiotics
High risk cardiac conditions – prosthetic valves, surgical shunts, PDAs, previous endocarditis
High risk procedures – Dental surgery, Respiratory tract surgery and bronchoscopy, GU surgery if infection
present, GI surgery (but not noninterventional endoscopy)
The subject is controversial – the British Society of Antimicrobial Chemotherapy published guidelines in
2006 which concluded that there was no evidence for the blanket use of penicillin prophylaxis in preventing
infective endocarditis. They therefore produced the guidelines as an ‘expert opinion’ which recommended
antibiotics only for those in whom the risk is high and carry a high mortality
The British Cardiovascular Society rejected this advice, and the NICE guidance that followed:
http://www.bcs.com/pages/news_full.asp?NewsID=18369177
http://jme.bmj.com/content/36/9/567.full.pdf+html
Most cardiologists would probably support the AHA guidelines over NICE or the BSAC
However given the more recent evidence on the threat of antimicrobial resistance, national policy is
increasingly turning towards antimicrobial minimisation
The perfect presentation – you are not expected to present to this level at finals! However see how it demonstrates
knowledge of relevant features
To complete my examination I would want to check the blood pressure, ECG, temperature chart and dipstick the urine for
blood and protein.
On examination this lady appears to have a well seated, well functioning, recent metallic aortic valve replacement. She has
a metallic 2nd heart sound, with no obvious signs of prosthetic valve complications – specifically she has no significant flow
or regurgitant murmur, no signs of heart failure, no peripheral stigmata of endocarditis, and no signs of anaemia from
haemolysis, though she has a few bruises consistent with anticoagulation.
She had no signs of a vascular harvest site to suggest a concurrent CABG.
As to the aetiology of his valve lesion leading to replacement, she is relatively young to have a calcific degenerative valve,
and there are no suggestions on the examination which suggest an aetiology, specifically I could see no signs of connective
tissue disease such as Marfans or Ehlers Danlos,or Ankylosing Spondylitis predisposing to aortic valve disease. Other
causes of aortic valve disease requiring replacement in a lady of this age would be rheumatic heart disease, endocarditis
and a congenital bicuspid valve.
To further investigate this lady I would wish to do an echocardiogram to assess valve function, specifically, any signs of
paravalvular leak, as well as a FBC and CRP to assess for active infection.
The management of a prosthetic valve is multidisciplinary. To minimise the effect on the patient’s life I would involve
physiotherapy and occupational therapy if there was any functional limitation from reduced cardiac function, cardiac
rehabilitation, and community support groups if appropriate.
Medical management would include anticoagulation to reduce the risk of valve thrombosis or embolus, and antibiotic
prophylaxis for high risk procedures. If I would ensure they were under regular follow up with the relevant cardiology clinic
with yearly echocardiographic assessment of valve function.
Case 2
To complete my examination I would want to check the blood pressure, ECG, temperature chart and dipstick the urine for
blood and protein.
On examination this gentleman appears to have a well seated, well functioning, recent metallic aortic valve replacement. He
has a metallic 2nd heart sound, with no obvious signs of prosthetic valve complications – specifically he has no significant
flow or regurgitant murmur, no signs of heart failure, peripheral stigmata of endocarditis, and no signs of anaemia from
haemolysis or bruises suggesting overwarfarinisation.
He had no signs of a vascular harvest site to suggest a concurrent CABG.
As to the aetiology of his valve lesion leading to replacement, I note the recent hickman line site which may suggest a recent
endocarditis, but there are no other suggestions on the examination which suggest an alternative aetiology, specifically I
could see no signs of connective tissue disease such as Marfans or Ehlers Danlos,or Ankylosing Spondylitis predisposing to
aortic valve disease. Other causes would be rheumatic heart disease, endocarditis as previously mentioned, degenerative
age related aortic stenosis and a congenital bicuspid valve.
To further investigate this gentleman I would wish to do an echocardiogram to assess valve function, specifically, any signs
of paravalvular leak, as well as a FBC and CRP to assess for active infection.
The management of a prosthetic valve is multidisciplinary. To minimise the effect on the patient’s life I would involve
physiotherapy and occupational therapy if there was any functional limitation from reduced cardiac function, cardiac
rehabilitation, and community support groups if appropriate.
Medical management would include anticoagulation to reduce the risk of valve thrombosis or embolus, and antibiotic
prophylaxis for high risk procedures. If there was an element of heart failure I would consider treatment symptomatically with
diuretic therapy, and agents to improve long term prognosis such as ACE inhibitors, beta blockers and digoxin as
appropriate. I would ensure they were under regular follow up with the relevant cardiology clinic with yearly
echocardiographic assessment of valve function.
Case 3
Few pearls of wisdom:
A metallic valve will always be left sided – in practice people hardly ever replace the tricuspid or pulmonary valves, but
occasionally do repairs. If you can’t work out which (try and do via 1st/2nd HS) then try with regards to the carotid pulse.
If you get a metallic valve always listen for regurgitant murmurs properly
If you can’t say for certain whether it is MR or AS – say systolic murmur, and describe how you tried to work it out (ie louder
LSE/Aortic area, harsh, present/absent 2nd HS, radiation to carotids or axilla) and give your differentials
Eg. Case 3 if unsure about findings - A perfectly reasonable presentation which would still get very good marks if you
continued with a sensible discussion – “ On examination the most obvious finding was a systolic murmur, for which my most
likely differentials are aortic stenosis or mitral regurgitation. It was loudest at both the LSE and apex, and did not radiate to
the carotids or axilla. It was louder on expiration. There were no peripheral stigmata of valvular lesions and no obvious
examination findings to suggest an underlying aetiology for either an aortic or mitral valve lesion. I would further investigate
by arranging an echocardiogram, and treat appropriately. “ etc etc