Endocarditis Heart-Related Infection of the Mitral Valve)

Endocarditis

Heart-related Infection of the Mitral Valve)

Endocarditis is a heart related infection of valves and some of the lining inside the muscle of the heart, or the 'endocardium'. This infection is uncommon, although not rare, and it can be serious. Infection may either be caused due to contraction during dental or medical procedures and/or in someone with a predisposing heart abnormality, but this is not always a given factor according to medical sources. Stated by Ferreri, et al. (2005) is: "Infective endocarditis (IE) is associated with substantial morbidity and mortality. Although it is relatively rare in children, its incidence may be increasing. (Ferreri, et al., 2005) The management of this disease is complex in cases of young patients in terms of intensive and after-care. Postoperative care is stated to be of a long-term nature as well. Diagnosis is through proper use of microbiological testing assisted through improvements in sensitivity of testing in diagnosis of this disease. Antibiotics are newer can be used in children due to their recent availability. Endocarditis may be of the noninfective type as well. In noninfective endocarditis the 'vegetations' are not detected through clinical means but may "serve as a nidus for colonization by circulating microorganism, producing emboli, or impairing valvular function." (paraphrased: The Merck Manual of Diagnosis, 2005)

Endocarditis

Heart-related Infection of the Mitral Valve)

Introduction

I. Incidence of the Disease 5

II. Etiology of the Disease 7

III. Pathophysiology of the Disease Process

IV. Clinical Manifestations Associated with the Disease Process

V. Nursing Care

Conclusion

References

Endocarditis

Heart-related Infection of the Mitral Valve)

Introduction

This disease was chosen as the topic of this research because a family member, specifically a child of the researcher has a high-risk of this disease due to mitral-valve with regulation and an ASD repair performed two years ago. Endocarditis is a heart related infection of valves and some of the lining inside the muscle of the heart, or the 'endocardium'. This infection is uncommon, although not rare, and it can be serious. Infection may either be caused due to contraction during dental or medical procedures and/or in someone with a predisposing heart abnormality, but this is not always a given factor according to medical sources.

Natural heart defense is present in the lining however, some bacteria do manage to break that barrier and feed on the blood of the individual also releasing what is called 'vegetations' which act as clot in the blood...thereby affecting heart valves and causing problems. (e.g. heart attacks, etc.) These individuals must take antibiotics in advance of having medical and dental procedures to avoid infection. These individuals might be someone who either has a risk due to valve replacement or perhaps the individual who is prone to the infection.

An individual with valve replacement would be considered to be at high-risk for this infection and would have to guard carefully against this disease before the aforementioned procedures. The following illustration labeled Figure 1.0 shows the area of the heart affected when this infection is present:

Source: http://www.heartpoint.com/endocarditis.html

I. Incidence of the Disease

Stated by Ferreri, et al. (2005) is: "Infective endocarditis (IE) is associated with substantial morbidity and mortality. Although it is relatively rare in children, its incidence may be increasing. (Ferreri, et al., 2005) Stated further is that "The epidemiology of heart disease in children has changed during the past 3 to 4 decades. Because of the increased survival rate of children with congenital heart disease (CHD) and the overall decrease in rheumatic valvular heart disease in developed countries, CHD now constitutes the predominant underlying condition for IE in children over the age of 2 years in these countries." Ferreri, et al., 2005

The management of this disease is complex in cases of young patients in terms of intensive and after-care. Postoperative care is stated to be of a long-term nature as well. Diagnosis is through proper use of microbiological testing assisted through improvements in sensitivity of testing in diagnosis of this disease. Antibiotics are newer can be used in children due to their recent availability. Infective endocarditis does not occur as often in children as adults and is stated to account for "01 in 1280 pediatric admissions per year. (Ferreri, et al. 2005 citation 2) However the same source stated that,."..the frequency of endocarditis among children seems to have increased in recent years. This is due in part to improved survival among children who are at risk for endocarditis, such as those with CHD and hospitalized newborn infants."

Prior to the decade of the 1970s children with infective endocarditis was in the range of 30% to 50%. The risk for endocarditis is eliminated in children through corrective surgery, although "surgery itself may be an important risk factor for the development of IE." Ferrieri, et al. AMA Journal, 2005) Further stated is that: "The highest annualized risk for IE was found in children who had had repair or palliation of cyanotic CHD. The risk was highest among those patients who had undergone surgery for obstruction to pulmonary blood flow and those who had undergone prosthetic aortic valve replacement. The incidence of IE in the first postoperative month is low for most defects and increases with time after surgery. However, when prosthetic valves or conduits are used in surgical repairs and hemodynamic problems persist, the risk for IE is high even in the immediate postoperative period (first 2 weeks after surgery)." (Ferrieri, et al. 2005)

Endocarditis may be of the noninfective type as well. In noninfective endocarditis the 'vegetations' are not detected through clinical means but may "serve as a nidus for colonization by circulating microorganism, producing emboli, or impairing valvular function." (paraphrased: The Merck Manual of Diagnosis, 2005) The development of symptoms that suggest arterial embolism in chronically ill patients makes noninfective endocarditis suspected. Other suspect symptoms are valvular vegetations without atrial myxoma during echocardiograms and in the case of negative blood cultures. Diagnosis is through "examination of embolic fragments after embolectomy." (The Merck Manual of Diagnosis, 2005) Prognosis is stated to be "generally poor due to the seriousness of predisposing conditions" (The Merck Manual of Diagnosis, 2005) Treatment is stated to "consists of anticoagulation with heparin or warfarin" (The Merck Manual of Diagnosis, 2005) along with predisposing conditions being treated as well.

II. Etiology and Classification of the Disease

Subacute bacterial edocarditis (SBE) is stated to be primarily caused by streptococcal species (especially viridians streptococci, microaerophilic and anaerobic streptococci, nonenterococcal group D. streptococci, and enterococci) and less commonly by Staphylococcus aureus, S. epidermidis, and fastidious Haemophilius sp.

Prosthetic valvular endocarditis (PVE) is stated to develop in approximately 2% to 3% of patients after one year of having their valve replaced. (The Merck Manual of Diagnosis and Therapy, 2005)

Right-sided endocarditis involves the tricuspid valve and the pulmonary valve and artery, although the second mentioned is less often involved and may results from use of illicit or IV drugs or from the central vascular lines which are known for the facilitation of microorganism entry.

III. Pathophysiology of the Disease Process

The left side of the heart is that which has the most often occurring infective endocarditis and involves the mitral, aortic, tricuspid, and pulmonic valves "in descending orders of frequency." (Ferrieri, et al., 2005) Major predisposing factors are bicuspid of calcific aortic valves, mitral valve prolapse, hypertrophic subaortic stenosis, prosthetic valves, Mural thrombi, arteriovenous fistulas, ventricular-septal defects, and patent ductus arteriosus which may become infected.

Symptoms and signs include: "low-grade fever, night sweats, fatigability, malaise, weight loss, valvular insufficiency" (Ferrieri, et al., 2005) with possible occurring of chips and arthralgias. Symptoms and signs are "nonspecific...highly variable, and may present insidiously, diagnosis requires a high index of suspicion, risk is greatest in patients with a history of cardiac valvular disease, recent invasive medical procedures, or dental work and in drug addicts." (Ferrieri, et al. 2005) Blood cultures numbering from three to five in a 24-hour period are needed for diagnosis due to "continuous bacteria in intravascular infections." (Ferrieri, et al. 2005)

IV. Clinical Manifestations Associated with the Disease Process

Clinical manifestation and diagnosis is stated "High-risk echocardiographic features include large and/or mobile vegetations, valvular insufficiency, suggestion of perivalvular extension, or secondary ventricular dysfunction For example, a patient with fever and a previously known heart murmur and no other stigmata of IE. +High initial patient risks include prosthetic heart valves, many congenital heart diseases, previous endocarditis, new murmur, heart failure, or other stigmata of endocarditis. Rx indicates antibiotic treatment for endocarditis." (Bayer, et al.,1998)

Source: http://circ.ahajournals.org/cgi/content-nw/full/111/23/e394/FIG1

Use of Echocardiography During Diagnosis and Treatment of Endocarditis

Early

Echocardiography as soon as possible (

TEE preferred; obtain TTE views of any abnormal findings for later comparison

TTE if TEE is not immediately available

TTE may be sufficient in small children

Repeat echocardiography

TEE after positive TTE as soon as possible in patients at high risk for complications

TEE 7-10 d after initial TEE if suspicion exists without diagnosis of IE or with worrisome clinical course during early treatment of IE

Intraoperative

Prepump

Identification…