[HSF] Endocarditis with splenic infarct

[rwmfglycar at aol.com]

Dear Nand, 

We saw a lot of endocarditis in the Bronx and began doing surgery for endocarditis quite early. Our first patients were generally in terminal acute heart failure. We realised that many of these had had features in the preceding week or two that could be used as markers for earlier intervention. We were also frustrated by being sent patients after they had had serious embolic incidents. Joel Strom, (great clinical cardiologist and superb echocardiographer) and  I started keeping track of these patients. We came to the conclusion that with vegetations of 1cm or more, embolism, leaflet tears and failure to sterilise with antibiotics were all more likely. Patients without or with small vegetations mostly were succesfully treated with antibiotics (provided of course that they had organisms senditive to antibiotics). The obvious pathologic point here is that the organisms continue to thrive within a large vegetation unreached by the antibiotics.
Yes , I would have operated. The results of following this policy were excellent.  Several times I had the sad experience of advising surgery in a patient with large vegetations detected in the first week after diagnosis, only to have a smart  cardiologist/ID combo put off referring the patient until one or more of the the events underlined above suddenly occurred and induced them, finally, to refer the patient.
Needless to say the ID guys can describe a case with a 1.2 cm vegetation that was finally sterilised without needing surgery My experience with patients of this kind was that they often came to surgery eventually anyhow. 
It is interesting that organisms were present in the vegetation. Did you send any of it for culture? Commonly there is no growth even with histologicallyvisible organisms but, sometimes there is even though the patient seems to have been doing well.
Refs. (sorry Michael no pdf's) Strom and I are on all these papers but the first author is the only one whose name I give:
Davis...Demonstration of vegetations by echocardiography in Bacterial Endocarditis; an indication for early surgery. Am J. Med. 1980; 69:57-68, 
Strom...Echocardiographic and surgical correlations in Bacterial Endocarditis. Circulation 1980;69:57-63
Strom...Effects of vegetation size on the outcome of patients with infective endocarditis.Circulation 1982;66(supp II):103.
Robbins...Influence of vegetation size on the clinical outcome of R sided endocarditis. Am. J. Med,1986;80(2):165-171.


asannasimha <prasannasimha at gmail.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Fri, 1 Jun 2007 7:54 am
Subject: Re: [HSF] Endocarditis with splenic infarct



A 1 cm vegetation is supposed to be an indication by itself due to its embolic risk. What is practiced or practical is different from what is preached which is a different issue. 
Prasanna 
nand kejriwal wrote: 
> Bob 
> 
> The size of vegetation was 1 cm on initial echo. 
> 
> The radiologist's opinion was that the appearance on the CT was in > keeping 
> with infarct rather than an abscess. The ID consultant told us that the 
> spleen was "likely to clear" the organisms and would not need > intervention. 
> The general surgeon also decided not to intervene at this stage. I > therefore 
> replaced his valve today. There was a large vegetation on the P1 segment. 
> The gram stain from the vegetation was positive for gram +ve cocci. The 
> patient is doing well in the ICU. I have made everyone aware to keep a > close 
> eye on the patient's abdomen. 
> 
> *Is it customary these days to treat active endocarditis as an > outpatient?* 
> 
> Bob, It was a medical decision. This patient is from our township and has 
> ready access to medical facilities. I believe he was taught to 
> self-administer the antibiotics under close supervision of the district 
> nurses. 
> 
> It appears from the responses that we do not have a consensus about the 
> management, if this patient had a splenic abscess. All three options were 
> suggested. 
> 
> A. Splenectomy first, followed by mitral, as suggested by Michael > (with the 
> risk that he could throw an embolus to brain) 
> 
> B. Concomitant splenectomy as suggested by Prasanna (Risk of bleeding 
> splenic bed, as Tea mentioned) 
> 
> C. Mitral followed by splenectomy a few days later as suggested by Bob > (Risk 
> of seeding the prosthesis). 
> 
> If this patient were referred before splenic infarct, what would you have 
> done? 
> 
> In other words, is one cm vegetation an indication for surgery by itself, 
> even though he was well clinically and responding well to treatment with 
> normalisation of inflammatory markers? 
> Nand 
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