valve

Question 1

Components of Wilkin’s score?

Answer 1

1. Valve mobility
2. Valve thickening
3. Valve calcification
4. Subvalvar thickening

MS: More than 8 bad for balloon

Question 2

RFs of LV rupture post MV surgery

Answer 2

1. excessive traction 2. excessive debridement of calcium 3. female 4. resection of pap m. 5. small left ventricle 6. large prosthesis #

Question 3

name the iteology of chronic primary MR

Answer 3

1. prolapse: myxomatous degeneration&Barlows valve (young)/fibroelastic deficiency (elderly) 2. IE 3. CTD (Marfans) 4. rheumatic 5. cleft MV 6. radiation heart disease #

Question 4

Valve surgery, what age to screen for CAD?

Answer 4

40y.o. #

Question 5

Dukes criteria:

Broad criteria for Definite vs probable infective endocarditis?

Answer 5

• Definite:
  
  • pathologic
  • 2major
  • 1major+3minor
  • 5 minor
• Possible I.E.:
  
  • 1major+1minor
  • 3 minor

Question 6

Name the 4 major dukes criteria

Answer 6

Dukes Major

1. 2 x Positive BC (Strep viridans, Strep bovis, HACEK, staph aureus, community-enterococcus)
2. 1 positive BC Coxiella burnetii or positive serology (anti-phase 1 IgG more than 1:800)
3. Endocardial involvement
4. Echo positive (oscillating intracardiac mass, abscess, new prosthetic valve dehiscence, or new regurgitation)

Question 7

HACEK ORGANISMS

Answer 7

Haemophilus sp. Aggregatibacter sp. Cardiobacterium hominis Eikenella corrodens Kingella sp.

Question 8

Name 5 duke minor criteria

Answer 8

1. Predisposition, heart condition, IDU 2. fever more than 38deg 3. Vascular phenomena (major art emboli, septic pulm infarcts, mycotoxins aneurysm, intracranial hemorrhage, conjunctival hemorrhage, janeway lesions) 4. Immunologic phenomenon (glomerulonephritis, Osler nodes, Roth spots, rheumatoid factor) 5. Microbio: positive BC OR positive serology #

Question 9

Lambl’s excrescence

Answer 9

Filiform fronds at site of valve closure; mitral more than aortic, collagen composition, can be substrate for emboli

Question 10

Echo features of high risk IE

Answer 10

1. 10mm or bigger 2. Severe valve insufficiency 3. Abscess or pseudo aneurysm 4. Valve perforation or dehiscence 5. Decompensated HF #

Question 11

Great echo predictor of embolic complications from IE

Answer 11

10mm or bigger veg on ant MV

Question 12

Echo features that suggest early surgery for IE

Answer 12

Vegetation : A. Persistent after embolization B. Ant mitral leaflet, esp greater than 10mm c. One or more embolic events within first 2 weeks of abx D. Increasing veg size on abx Valve dysfunction: A. Acute AI or MR w ventricular failure B. HF not responsive to Med rx Valve perforation or rupture: A. Peri valvular extension B. Dehiscence, rupture or fistula C. new HB C. Large abscess or extension on Abx

Question 13

Duke Major criteria

Answer 13

1. Blood Culture positive for IE (2, >12 hours apart) 2. single blood culture for Coxiella burnetii or anti-phase 1 IgG Ab titre greater than 1:800 3. endocardial involvment 4. Echo positive (oscillating intracardiac mass on valve or supporting structures, in the path of regurgitant jets, or on implanted materials; abscess; new dehiscence of prosthetic valve or new regurgitation)

Question 14

Duke Minor Criteria

Answer 14

1. predisposition (heart condition or IDU) 2. temp greater than 38degrees 3. vascular phenomena, major art emboli, septic pulmonary infacts, mycotic aneurysm, intracranial hmorrhage, conjunctival hemorrhage, janeway lesions 4. immunological phenomena glomerulonephritis, osler nodes, roth spots, rheumatoid factor 5. microbiological evidence (not meeting major criteria)

Question 15

3D vs. 2D TEE

Answer 15

3D has lower temporal and lateral resolution therefore, overestimates veg size and difficulty visualizing fast moving structures

Question 16

define inoculum effect which antibiotics most susceptible which least susceptible

Answer 16

High bacterial density causes decreased antimicrobial activity of an antibiotic - beta lactams and glycopeptides most susceptible to this problem (?due to loss of penicillin-binding protein during stationary-growth phase of bacteria) - fluoroquinolones and aminoglycosides least affcted

Question 17

4 common PK/PD parameters that predict antibiotic efficacy

Answer 17

1. max serum concentration/MIC 2. AUC 24/MIC 3. duration of time that serum concentration exceeds MIC 4. duration of postantibiotic effect MIC = minimum inhibitory concentration

Question 18

most common organisms causing early (within 1 year) prosthetic valve endocarditis

Answer 18

1. coag neg staph 2. S. aureus 3. aerobic gram-neg bailli 4. fungi 5. corynebacterium sp 6. legionella sp

Question 19

most common organisms causing late PVE

Answer 19

1. coag-neg staph 2. S. Aureus 3. VGS 4. Enterococci 5. Fungi 6. Corynebacterium sp

Question 20

most common organisms causing IE of indwelling devices

Answer 20

1. S aureus
2. coag-neg staph
3. fungi
4. aerobic gram-neg bacilli
5. corynebaterium sp

Question 21

most common organisms causing IE of transplantation

Answer 21

1. S aureus 2. aspergillus fumgatus 3. enterococcus sp 4. candida sp

Question 22

most common organisms causing IE in IDU

Answer 22

1. S aureus 2. coag-neg staph 3. beta hemolytic strep 4. fungi 5. aerobic gram-neg bacilli (inc psudomonas aeruginosa) 6. polymicrobial

Question 23

orgnaisms responsible for NVE in non IDU

Answer 23

1. S aureus 2. VGS or Strep gallolyticus 3. enterococcus 4. HACEK 4. coag neg staph (s. epidermidis)

Question 24

non-infectious endocarditis causes

Answer 24

1. APA 2. neoplasia associated - atrial myxoma - marantic endocarditis - neoplastic D - carcinoid 3. autoimmune associated - rheumatic carditis - SLE - Polyarteritis nodosa - behcet’s D 4. post sx - thormbus - stitch - changes 5. Misc - eosinophilic heart D - ruptured mitral chordae - myxomatous degeneration

Question 25

causative agents of acute NVE

Answer 25

S aureus betahemolytic trep (GAS and GBS) aerobic gram neg bacilli

Question 26

causative agents of subacue NVE

Answer 26

S aurus VGS (ie. alphahemolytic strep) HACEK enterococci

Question 27

causative agents of PVE less than 1 year

Answer 27

S aureus CoNStaph diphtheroids enterococci aerobic gram neg bacilli

Question 28

causative agents of PVE \> 1 year

Answer 28

staphylococci VGS Enerococci

Question 29

mortality rates of fungal IE

Answer 29

more than 80%

Question 30

fungal IE - causative agents - Rx

Answer 30

Candida aspergillus mycoses rx: - early Surgery - amphotericin B + flucytosine for over 6 weeks - lifelong suppressive rx with fluconazole

Question 31

frequency of systemic embolization in IE

Answer 31

22-50%

Question 32

organisms most likely to embolize in IE

Answer 32

Staph aureus candida HACEK

Question 33

where do CNS embolizations go to?

Answer 33

more than 99% to MCA territorry

Question 34

RFs for embolization in IE

Answer 34

1. size (10mm on left) 2. MV involvment, esp ant leaflet 3. organism (Staph, candida, HACEK)

Question 35

Independant predictors of mortality in IE

Answer 35

1. DM 2. S. aureus infection 3. APACHE II score 4. embolic events (i.e. stroke)

Question 36

independent RFs of periannular extension in IE

Answer 36

1. aortic valve involvement (10-40% NVE; 56-100% PVE) 2. current IDU

Question 37

weakest point of aortic valve annulus

Answer 37

near membranous septum and AV node

Question 38

systemic embolization sites of IE

Answer 38

brain, lung, coronaries, spleen, gut, extremities

Question 39

define mycotic aneurysms

Answer 39

septic emboli to arterial vasa vasorum or intraluminal space and subsequent spread of infection from intima outwards; commonly at branching points - intracranial - extracranial (visceral, upper & lower extremities)

Question 40

mortality rate in aorto-cavitary fistulization IE

Answer 40

41%

Question 41

mortality rate in Intracranial mycotic aneurysms

Answer 41

60%

Question 42

common causative agents in Intracranial mycotic aneurysms

Answer 42

streptococci (50%) Staphylococci (10%)

Question 43

period of greatest risk for systemic emboli in IE

Answer 43

before or within the first 1-2 weeks of antimicrobial therapy

Question 44

indications for early surgery in IE

Answer 44

LEFT sided: CLASS 1: 1. Fungal, VRE or non-HACEK Gm -ve aerobic bacilli (esp Pseudomonas aruginosa) 2. HF 3. HB, abscess, or destructive penetrating lesions 4. Persistent fever or bacteremia more than 1 week on ABx 5. recurrent emboli or enlarging vegetations on ABx (IIa, B) 6. severe regurge AND mobile veg greater than 10mm (IIa, B) 7. veg greater than 10mm, esp on ant mitral leaflet or on prosthetic valve (IIb, C) 8. relapsing PVE (IIa, C) RIGHT sided (IIa, C) 1. right HF secondary to severe TR and poor response to abx 2. sustained infection with diff to treat organisms (fungal, multidrug resistant) 3. lack fo resonse to abx 4. TV veg greater than 20mm and recurrent PEs on Abx

Question 45

process of IE development

Answer 45

1. formation of NBTE (plt + fibrin) on valve or area of endothelial damage 2. random bacteremia 3. adherence of bacteria to NBTE 4. proliferation of bacteria wihin a vegetation

Question 46

difference between left and right sided IE lesions

Answer 46

Left sided lesions are uninhibited by host defenses, bacteria grows rapidly to reach 10(8)-10(12) right sided lesions are inhibited by PMN and plt derived antibacterial proteins

Question 47

x% of bacteria in both left and right sided IE vegetations are metabolically INactive

Answer 47

90% thus very resistent to antibiotics

Question 48

condition at risk of IE

Answer 48

1. previous IE 2. prosthetic heart valve 3. Rheumatic HD 4. Congenital HD 5. MVP

Question 49

best prevention of IE in patients with underlying predisposing cardiac conditions

Answer 49

improved access to dental care and increaed emphasis on oral health pre valve surgery dental evaluation & rx

Question 50

mortality risk of prosthetic vlave endocarditis is ...... than native valve endocarditis

Answer 50

Greater

Question 51

compared to NVE, PVE is more likely to

Answer 51

1. die 2. develop HF 3. need Sx 4. perialvular extension of infection 5. other complications

Question 52

worst prognosis with IE

Answer 52

prosthetic material + complex cyanotic CHD in children under 2

Question 53

conditions with the highest risk of ADVERSE OUTCOME from IE should get prophylaxis for certain procedures - name the conditions - name the procedures - name the antibiotic

Answer 53

CONDITIONS 1. prosthetic valve material (valve/ring/band) 2. previous IE 3. unrepaired or incompletely repaired cyanotic CHD 4. 6 months after complete repair of CHD 5. post transplant valvulopathy PROCEDURES 1. all dental 2. invasive respiratory tract/infected skin/infected MSK (incision & biopsy) ABx amoxicillin 2g PO 60min pre-procedure or Ancef 1g IV if allergic, give clindamycin PO or IV

Question 54

SAM: when it can occur

Answer 54

1. HOCM w basal ASH and leaflet-septal contact 2.TGA w intact IVS 3. post MV repair

Question 55

Culture data to qualify as a Duke Major criteria?

Answer 55

* 2 x Positive BC: 1. *Strep viridans* 2. *Strep bovis* 3. *HACEK,* 4. *staph aureus* 5. *community-enterococcus* * 1 positive BC * *Coxiella burnetii*