Investigation into paravalvular abscess in infective endocarditis. Epidemiology, Presenting symptoms, Diagnosis, Complications, Abscess formation, Prognosis

1. BY: KHALED GHANAYIM
DEPARTMENT OF INTERNAL MEDICINE G’, AFULA HAEMEK
PARAVALVULAR ABSCESS IN INFECTIVE ENDOCARDITIS

2. OVERVIEW
• Epidemiology
• Presenting symptoms
• Diagnosis
• Complications
• Abscess formation
• Prognosis
• Take home message

3. EPIDEMIOLOGY
• Paravalvular complications - 9.8% to 40% in native valve IE
56% to 100% of prosthetic valve endocarditis1
• More common in women (higher prevalence of MVP)
• Historically a rare finding only in necropsy patients2
• Severe complication of bacterial endocarditis
• Aortic valve having a higher predisposition, also prosthetic valves
• Indication for surgery – urgency varies3
• Earlier surgical intervention -> more favorable prognosis3
1. Ann. Thorac. Surg., May 18, 2016. DOI: https://doi.org/10.1016/j.athoracsur.2016.02.019
2. Circulation. 1976;54:140–145. DOI: https://doi.org/10.1161/01.CIR.54.1.140
3. Circulation. 2010;121:1141–1152. DOI: https://doi.org/10.1161/CIRCULATIONAHA.108.773598

4. PRESENTING SYMPTOMS
• General weakness
• Weight loss
• Fever
• Chills
• Shortness of breath
• Arthralgia
• Stroke

5. DIAGNOSIS
• Clinical evaluation
• Blood tests and cultures
• ECG
• CT scan1
• Echocardiogram – TEE > TTE
• MRI scan
1. Br Heart J. 1984 Nov; 52(5): 591–593. DOI: 10.1136/hrt.52.5.591

6. TEE demonstrating large aortic
vegetation with ring abscess
vegetation
abscess
* EMEK medical center, 2021 Jun.

7. ABSCESS FORMATION
* Circulation. 1976;54:140–145. DOI: https://doi.org/10.1161/01.CIR.54.1.140

8. ABSCESS FORMATION
* EACVI 2010 Mar; 11(2): 202-219. DOI: 10.1093/ejechocard/jeq004

9. COMPLICATIONS
• Persistent infection
• Heart failure
• Conduction blocks – 1st to full AV block
• Fistulae
resultant intracardiac or pericardial shunts
• Death
* Clinical Anatomy 2009 Jan;22(1): 99-113. DOI: https://doi.org/10.1002/ca.20700

10. TREATMENT
Medical therapy only1
◦ Small abscess cavities (<1 cm)
◦ Sensitive organisms
◦ No evidence of coexistent heart block or valve destruction
* Serial monitoring with TEE is mandatory
Surgery2
◦ Abscess opening
◦ Valve replacement
◦ Pericardial patching
1. Circulation. 2010;121:1141–1152. DOI: https://doi.org/10.1161/CIRCULATIONAHA.108.773598
2. Ann. Thorac. Surg., May 18, 2016. DOI: https://doi.org/10.1016/j.athoracsur.2016.02.019

11. PROGNOSIS
• Untreated, prognosis is extremely poor
• Intra-operative mortality ∼ 20%1
• Post operative – 5 year survival is ∼ 60%1
• Overall mortality of 41%2
1. Ann. Thorac. Surg., May 18, 2016. DOI: https://doi.org/10.1016/j.athoracsur.2016.02.019
2. Circulation. 2010;121:1141–1152. DOI: https://doi.org/10.1161/CIRCULATIONAHA.108.773598

12. ABSCESS OR NO ABSCESS?
When is an abscess suspected1?
• Fulminant presentations
• Aortic or prosthetic valve involvement
• History of aortic stenosis
• Valvular regurgitation
• Pericarditis
• Persistent fever
• Atrioventricular or bundle branch block
• Infection with a "virulent" pathogen
(staphylococcus, pneumococcus, non-alpha streptococcus, P. aeruginosa)
• History of IV drug use
1. Chest 1995 Apr;107(4): 898-903. DOI: https://doi.org/10.1378/chest.107.4.898

13. TAKE HOME MESSGAE
• Valvular abscess is a serios complication of IE
• TEE is warranted in virtually all patients with suspected IE1
• Serial ECGs are mandatory with attention to new blocks
• Close attention to aortic and prosthetic valves
• Early surgical intervention is highly recommended2
• Poor prognosis
1. EACVI 2010 Mar; 11(2): 202-219. DOI: 10.1093/ejechocard/jeq004
2. Circulation. 2010;121:1141–1152. DOI: https://doi.org/10.1161/CIRCULATIONAHA.108.773598

14. THANK YOU!