Dr. Grapsa works at the Guys and St Thomas NHS Trust as a consultant cardiologist. Dr. Grapsa is an associate professor at King's College in London and is part of the UK's premier structural valve disease group. She also serves as the editor-in-chief of JACC Case Reports, the chair of the European Society of Cardiology's Women Task Force in Imaging, and the secretary of the ESC's Valvular Heart Disease Council.
In this podcast Dr. Grapsa discusses Staphylococcus Aureus Infective Endocarditis.
Link to 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.
• 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.
• 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.
• 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.
• 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.
• 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.
• 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.
JACC Patient Pathways is a new initiative from the JACC family to reflect the multidisciplinary collaboration that contributes to optimal patient care and decision-making. The Pathways will highlight the evidence-based discussions that are necessary to solve a clinical problem through an actual patient’s journey.
As clinicians are faced with challenging clinical cases, it is important to understand how current knowledge based on clinical guidelines and the published data can inform decisions. JACC Patient Pathways is a multiparametric approach to this patient journey that provides an interactive illustration, a paper that integrates the clinical case with current evidence, and a video discussion between expert clinicians.
This paper, which the authors are requesting to be copublished with JACC and JACC: Case Reports, begins with the clinical case and continues with mini reviews on the basic considerations of the case. The scope of the paper is not to provide an extensive review of the topic, but rather to act as guidance for clinicians who may encounter similar cases.
A 19-year-old female patient presented to the emergency department with 5 days of vomiting, fever, intermittent abdominal pain, myalgia, and weakness. She arrived in the United Kingdom from Brazil 6 weeks ago during the coronavirus disease-2019 (COVID-19) pandemic. On presentation, the patient was in extremis: she was hypoxic, acidotic, and hypotensive with a blood pressure of 86/49 mm Hg, a heart rate of 140-150 beats/min, and a respiratory rate of 22 breaths/min. Electrocardiography (ECG) demonstrated sinus tachycardia (Figure 1). She was subsequently referred for extracorporeal membrane oxygenation (ECMO). Her chest x-ray (Figure 2) demonstrated opacified lungs. It was determined that she required a full-body computed tomography (CT) scan on her way to the intensive care unit. The patient was septic and had acute renal injury. She also tested negative for COVID-19, HIV, and hepatitis. Blood cultures proved to be positive for Staphylococcus aureus (Figure 3).
Shortly after undergoing CT scanning, she received a transthoracic echocardiogram (TTE) (Videos 1, 2, 3, 4, 5, and 6), which demonstrated extensive vegetations on the mitral valve and right ventricular wall and good biventricular systolic functioning. She was therefore diagnosed with Staphylococcus aureus endocarditis of the mitral valve and right heart chambers.
After a multidisciplinary meeting with the surgeons, critical care clinicians, hematology, infectious disease, and cardiology, it was determined that the patient required urgent surgery within 24 hours of admission. She underwent mitral and tricuspid valve repair (Figure 6) and experienced mild residual mitral regurgitation immediately postoperatively (Videos 7, 8, 9, 10, 11, and 12). The ECGs were performed during the same day, with TTE taking place in the morning followed by the intraoperative transesophageal echocardiogram (TEE) in the afternoon.