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• W1996991572 abstract "Although the development of bactericidal and synergistic antibiotics and also prosthetic cardiac valvular surgery have dramatically improved the treatment and subsequent prognosis of patients with infective endocarditis, this disease remains one of the most vexing problems that confront the modern cardiologist, infectious disease specialist, and cardiovascular surgeon. Despite these advances, patients with refractory bacterial endocarditis often provoke polemic discussions over the optimal duration of antibiosis, the localization of specific valvular involvement, the degree of hemodynamic embarrassment, and the desirability of either emergent or semi-emergent surgical intervention. Moreover, the flush of success aroused by clinical and hemodynamic improvement or by the development of sterile cultures of blood after prosthetic valvular replacement often turns to morbid discouragement as the resistant infection again suddenly raises its ugly head. With an ultimate mortality of 30 percent for medically treated cases1Griffin FM Jones G Cobbs CC Aortic insufficiency in bacterial endocarditis.Ann Intern Med. 1972; 76: 23Crossref PubMed Scopus (102) Google Scholar and a mortality of approximately 25 percent for surgically treated cases,2Black S O'Rourke RA Karliner JA Role of surgery in the treatment of primary infective endocarditis..Am J Med. 1974; 56: 357-369Abstract Full Text PDF PubMed Scopus (37) Google Scholar there is without doubt a need for further careful clinical investigation of the role and efficacy of diagnostic methods that identify the site and severity of infection, optimal antibiosis, the indications for surgical intervention and its relation to the patient's hemodynamic profile, and innovative surgical techniques for repair of infected valves and associated great vessels. In this issue of Chest (see page 576), Mills and associates provide a constructive analysis of the role and risk of cardiac catheterization and angiographic studies in identifying and documenting the anatomic loci and associated pathophysiologic findings of infectious endocarditis. Noteworthy in the analysis by Mills et al was the conclusion that catheterization and angiographic studies are most useful if more than one left-sided valvular lesion is present, if extravalvular disease mimics heart failure, or, perhaps most important, if extravalvular infection is present. Mills et al point out that left-sided cineangiographic studies, in particular, often reveal the presence and severity of mitral or aortic valvular insufficiency in patients in whom the findings from bedside examination were either normal or ambiguous. Also, supravalvular aortographic studies frequently will identify patients who have persistent infection due to periaortic sinus tracts or aneurysms of the sinuses of Valsalva; however, it is notable that this diagnostic method failed to identify nearly half of the annular erosions subsequently discovered at surgery. The careful inspection of the aortic root and sinuses of Valsalva is thus of obvious importance at the time of surgical intervention, despite a normal ascending aortogram. In my experience, several other valuable aspects of cardiac catheterization and angiographic studies in the presence of infectious endocarditis deserve emphasis. Right-sided vegetations have emerged as a significantly more common problem as the “drug culture” has grown and flourished. Detection of such tricuspid or pulmonary valvular involvement often necessitates careful scrutiny of the precordium for signs of insufficiency of one or both of these valves; moreover, physiologic maneuvers to augment the intensity of murmurs of these lesions by increasing right-sided venous return are invaluable in solidifying the clinical impression of right-sided valvular insufficiency; however, in some patients, unequivocal proof of either tricuspid or pulmonary regurgitation can only be obtained using either right cardiac catheterization with intracardiac phonocardiographic studies or dye-dilution curves with indocyanine green (Cardio-Green), or both.3Collins NP Braunwald E Morrow AG Detection of pulmonic and tricuspid valvular regurgitation by means of indicator solutions..Circulation. 1959; 20: 561-568Crossref PubMed Scopus (7) Google Scholar, 4Pazin J Peterson KL Griff FW et al.Determination of site of infection in endocarditis..Ann Intern Med. 1975; 82: 746-750Crossref PubMed Google Scholar Also, when surgical extirpation without prosthetic replacement of either the tricuspid or pulmonic valve is being considered for a patient with right-sided endocarditis refractory to antibiotic therapy,6Dillon JC Feigenbaum H Konecke LL et al.Echocardiographic manifestations of valvular vegetations..Am Heart J. 1973; 86: 698-704Abstract Full Text PDF PubMed Scopus (222) Google Scholar I have found it useful to obtain quantitative analysis of titers from cultures of blood from selected sites both proximal and distal to the tricuspid and pulmonic valves at the time of cardiac catheterization.4Pazin J Peterson KL Griff FW et al.Determination of site of infection in endocarditis..Ann Intern Med. 1975; 82: 746-750Crossref PubMed Google Scholar I have now applied this technique to patients with refractory endocarditis on three separate occasions, and in each instance the samples of blood with the highest colony counts correlated with the specific valvular involvement at the time of open-heart surgery; however, more extensive implementation of this approach for the identification of the site of intracardiac infection will be necessary before it can be recommended as a generally useful diagnostic measure in patients with bacterial endocarditis. It may be found that so-called fastidious organisms will not grow in sufficient abundance to allow reliable quantitative colony counts between different loci in the heart. Echocardiography represents an additional diagnostic method that has gained significant recognition for use in identifying the anatomic loci and hemodynamic sequelae of infectious endocarditis. Dillon and co-workers6Dillon JC Feigenbaum H Konecke LL et al.Echocardiographic manifestations of valvular vegetations..Am Heart J. 1973; 86: 698-704Abstract Full Text PDF PubMed Scopus (222) Google Scholar first reported in 1973 the ability of ultrasound to detect valvular vegetations as characteristic thickened echoes on the mitral or aortic leaflets, and numerous other investigators have since documented and amplified upon the observations of Dillon et al. Also, echocardiographic studies have been shown to be extremely useful in the setting of acute aortic regurgitation due to fenestrations of the valvular leaflets where the left ventricle is forced to operate on a steep portion of its pressure-volume curve, where middle and late diastolic pressures are severely elevated and exceed the left atrial pressure, and where the mitral valve thereby closes relatively early in diastole. This abbreviation of diastolic filling of the left ventricle can be readily detected by echocardiographic recordings of the motion of the anterior and posterior leaflets of the mitral valve and their temporal relationship to the surface electrocardiogram. Premature closure correlates with a severe volume overload that is marginally compensated and thus serves as a relatively objective marker of the need for emergency replacement of the aortic valve.7Mann T McLaurin L Grossman et al.Acute aortic regurgitation due to infective endocarditis..N Engl J Med. 1975; 293: 108-113Crossref PubMed Scopus (110) Google Scholar Serial echocardiograms (weekly) also may be useful in patients with fevers of unknown origin and where bacterial endocarditis is suspected but cannot be proven by cultures of blood and other clinical characteristics. In one patient in my experience, serial echocardiograms defined the gradual development over a six-week period of a large obstructive vegetation on the mitral valve due to infection with Hemophilus parainfluenzae. There is hope on the horizon for further improved modes for early precise detection of infectious endocarditis. Imaging of valvular vegetations may become feasible using either computerized axial tomographic studies or phase-array two-dimensional echocardiographic studies. Range-gated Doppler's ultrasound may provide a further noninvasive means of detecting subtle derangements of patterns of intracardiac flow produced by otherwise clinically silent vegetations. Improved bioprostheses for valvular replacement may be found which will be considerably more resistant to harboring the bacteria and fungi that cause infectious endocarditis. These potential advances hopefully will minimize the controversy that presently surrounds the diagnosis and management of this difficult clinical problem." @default.
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