Echocardiography should be administered expeditiously as the optimal modality for the initial work-up of suspected IE and in the management of most patients with IE. TEE improves sensitivity and TTE improves specificity in detecting complications of IE, so both tests are necessary. TEE is superior for detecting small vegetations.
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CTA is highly sensitive for identifying complications of IE (eg, abscess or aneurysm) and complex IE (eg, PVE), in patients with suboptimal echo imaging and surgical planning in IE.
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18F-FDG PET-CT: Although not sufficiently sensitive for diagnosing NVE, molecular imaging (mainly with 18F-FDG PET-CT) is an important advance in PVE and CIED-IE as well as in detecting systemic infective foci/septic emboli that often lead to changes in patient management. Use of 18F-FDG PET-CT influences outcomes and is recommended in European IE guidelines but not in the AHA statement.
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WBC scintigraphy is a specific whole-body test to locate infection in prosthetic valve and CIED IE but, currently, there is no clear recommendation in guidelines. It is quite useful in early PVE (where PET-CT, when done <3 months postsurgery, may pick up nonspecific sterile inflammation) and can best identify metastatic foci of infection.
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Surgery: Repair is the surgical method of choice when applicable. Main targets of surgery are the complete removal of infective tissue and reconstruction of affected tissue. In complex IE cases, bioprosthetic valves may be superior to metallic in terms of anticoagulation and have less bleeding risk.
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Antibiotic prophylaxis: There is harmony in the French, AHA, and ESC guidelines to limit prophylaxis to patients with the highest risk of a poor outcome with IE, including prosthetic heart valves, valve repair that includes annuloplasty rings or clips, left ventricular assist devices, complex congenital heart defect either repaired or unrepaired, and orthotopic transplanted hearts with valvulopathy. The United Kingdom’s NICE took the approach of recommending ABx prophylaxis for no group on a routine basis.
Abstract
A 19-year-old female patient presented with Staphylococcus aureus infective endocarditis, with suspected subdural brain hemorrhage, disseminated intravascular coagulopathy, and septic renal as well as spleen infarcts. The patient had extensive vegetations on the mitral and tricuspid valves and underwent urgent mitral and tricuspid repair. This paper discusses the clinical case and current evidence regarding the management and treatment of Staphylococcus aureus endocarditis.
Vinod Thourani, MD, served as Guest Associate Editor for this paper. Javed Butler, MD, MPH, MBA, served as Guest Editor-in-Chief for this paper.
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