Physical Exam Pearls: Aortic Regurgitation:
Characteristic Murmur: high pitched,
Location: LLSB (valvular) or RLSB
Associated findings: enlarged,
displaced apical impulse; S3 or S4;
increased pulse pressure (Traube’s
sign, Duroziez’s murmur, Corrigan
-Early closure of the mitral valve
generally produces a soft or absent S1,
which can occasionally be heard in middiastole
-Aortic component of S2 is often soft,
while P2 is usually increased, reflecting
-Murmur: low-pitched, early diastolic
murmur beginning after S2
-Pulse pressure: decreased, pulse is
Guidelines for Surgery in Native
Valve Infective Endocarditis
Deva Sharma, MD
• Surgery was not an option for the
management of IE until 1961, when Kay &
colleagues excised fungal vegetations
from the tricuspid valve of a patient
• (Kay et al. N Engl J Med 1961; 264:907)
• In 1965, an aortic valve was successfully
replaced in a patient with IE 2/2 to
(Wallace et al. Circulation 1965; 31:450).
• Over the last 3 decades, valve
replacement & even repair have become
more common in the management of
ACC/AHA Guideline Summary:
Surgery for Native Valve Endocarditis
•Valve stenosis or regurgitation leading to heart
•AR or MR with hemodynamic evidence of elevated
LVED or atrial pressures such as premature closure of
the mitral valve with aortic regurgitation or moderate
to severe pulmonary hypertension.
•IE due to fungal or other highly resistant organisms.
•Complications such as heart block, annular or aortic
abscess, or destructive penetrating lesions such as
fistula formation, mitral leaflet perforation with IE of
the aortic valve, or infection in annulus fibrosis.
•Recurrent emboli and persistent
vegetations despite appropriate
•Mobile vegetations larger than 10 mm
with or without emboli.
J Am Coll Cardiol 2006; 48:e1.
European Society of Cardiology Guideline Summary:
Surgery for Native Valve Endocarditis:
Heart Failure (AR or MR):
•Severe acute regurgitation or valve
obstruction causing refractory pulmonary
edema or cardiogenic shock (EMERGENT)
•Fistula into a cardiac chamber or
pericardium causing refractory pulmonary
edema or shock (EMERGENT)
•Severe acute regurgitation or valve
obstruction and persisting heart failure or
echocardiographic signs of poor
hemodynamic tolerance (early mitral closure
or pulmonary HTN) (URGENT)
•Severe regurgitation and no heart failure
Habib et al. Eur Heart J 2009; 30:2369
Uncontrolled Infection: ALL URGENT
•Locally uncontrolled infection (abscess,
false aneurysm, fistula, enlarging veg)
•Persisting fever and positive blood
cultures >7 to 10 days
•Infection caused by fungi or multiresistant organisms
Prevention of Embolism: ALL URGENT
•Large veg (>10 mm) following ≥ 1
embolic episodes despite appropriate abx
•Large veg (>10 mm) & other predictors of
complicated course (HF, persistent
•Very large vegetations (>15 mm)
Timing of Surgery:
In some cases, surgical intervention is delayed due to
concerns about placing a prosthetic valve into actively
On the other hand, early surgical intervention may be
curative and life saving if it is done as early as the 1st
or 2nd day of diagnosis in patients with acute valvular
regurgitation and severe CHF.
Early surgery is recommended in patients with clear
indications (ex, aortic regurgitation with heart failure,
perivalvular extension or persistent infection, or high
embolic risk), b/c prognosis is poor w/ medical therapy
(Foghsgaard et al, Scand J Infect Dis 2008; 40:216)
Although some studies show lower mortality rates with
a longer duration of antibiotic therapy prior to surgery,
these studies are affected by selection bias as patients
who survive longer with medical therapy alone are at
lower risk (Barsic et al, Clin Infect Dis 2013; 56:209)
Choice of Procedure:
• When surgery is performed in the
setting of active infection, the 2006
ACC/AHA guidelines recommended
that valve repair is preferred to valve
• Valve repair may be particularly
desirable in young IV drug users in
whom compliance with AC required for
mechanical prosthetic heart valves is
often poor, & use of a bioprosthetic
heart valve is associated with a high
rate of structural deterioration over
the long term.
Predictors of Poor Surgical Outcomes:
• Five year survival rate for native valve
endocarditis (aortic & mitral) is ~ 7579%
(Delay et al, Ann Thorac Surg 2000; 70:1219).
• Predictors of operative morality:
preoperative shock, perivalvular
abscess, left ventricular ejection
fraction <40%, & infection with
Staphylococcus aureus (David et al, J Thorac
Cardiovasc Surg 2007; 133:144)
• Patients undergoing dialysis also have
higher operative mortality, up to 25%
(Rankin et al, J Heart Valve Dis 2007; 16:617)
A 38 year-old man is admitted to the hospital for fever and SOB. He reports a 4 week history
of malaise, recurrent fevers with chills, myalgia, and decreased appetite.
On physical exam, temperature is 39.0°C (102.2°F), BP is 138/60 and pulse is 112. O2
saturation is 92% on ambient air.
JVD is increased. The carotid upstrokes are brisk. There is an early systolic ejection click
after S1 followed by a grade III/VI midpeaking systolic ejection murmur at the RUSB. S2 is
normal but followed by a grade III/VI decrescendo diastolic murmur at the LLSB. An S3 and
bibasilar crackles are heard.
Lab findings include a Hgb of 9.0 and WBC count of 17.5 K with a left shift. He is empirically
treated with vancomycin and gentamycin intravenously.
Blood cultures are positive for viridans streptococci, susceptible to penicillin.
TEE shows normal LV size and systolic function. The aortic valve is biscuspid with fusion of
the right and left cusps. There is mild aortic stenosis. There is severe aortic valve
regurgitation, with a leaflet perforation. An oscillating vegetation is found on the aortic
valve, and echolucency (fluid) is seen around the aortic annulus posterior to this region.
Which of the following is the most appropriate next step in management?
(B)Aortic valve replacement
Answer: B (aortic valve replacement)
• In patients with endocarditis complicated by heart failure, abscess,
severe regurgitation or hemodynamic derangements, valve
replacement should be performed urgently, without delay for
response to antibiotic therapy.
• Addition of rifampin is not indicated in this patient with viridans
• Cardiac catheterization is not indicated in this patient and may
increase the risk of embolization of vegetation or worsening
• Cardiac catheterization before planned cardiac surgery is indicated
in patients with risk factors for coronary artery disease, which are
not present in this patient.
A 55 year-old man is admitted to the hospital with a 3 week history of
intermittent fevers and SOB. He has a mechanical aortic valve. He
takes warfarin and no other medications.
On physical exam, he has a temperature of 40.0°C (104.0°C), BP is
148/50, pulse is 93 and RR is 22. A grade II/VI early systolic murmur
and early diastolic murmur are noted at the cardiac base.
EKG shows sinus tachycardia with a new 1st degree AV block (prolonged
PR interval). Blood cultures obtained on admission demonstrate grampositive cocci in clusters. Serum Cr level is 2.3.
Which of the following is the most appropriate initial study to obtain?
(A)Cardiac CT angiography
(B)Cardiovascular magnetic response imaging
• TEE is the initial test of choice when there is a moderate or
high pretest probability of endocarditis (ex- in patients with
staphylococcal bacteremia or fungemia, a prosthetic heart
valve or an intracardiac device)
• TTE is ~ 32% sensitive overall in the diagnosis of infective
• Cardiac CT angiography & cardiovascular MR imaging may
be helpful in identifying an aortic root abscess, but TEE is
more likely to identify cardiac vegetations (also, the patient
here has an elevated serum Cr)
KAY JH, BERNSTEIN S, FEINSTEIN D, BIDDLE M. Surgical cure of Candida albicans endocarditis with
open-heart surgery. N Engl J Med 1961; 264:907.
WALLACE AG, YOUNG WG Jr, OSTERHOUT S. TREATMENT OF ACUTE BACTERIAL ENDOCARDITIS
BY VALVE EXCISION AND REPLACEMENT. Circulation 1965; 31:450.
Vikram HR, Buenconsejo J, Hasbun R, Quagliarello VJ. Impact of valve surgery on 6-month
mortality in adults with complicated, left-sided native valve endocarditis: a propensity analysis.
JAMA 2003; 290:3207.
Durack DT. Evaluating and optimizing outcomes of surgery for endocarditis. JAMA 2003;
Aksoy O, Sexton DJ, Wang A, et al. Early surgery in patients with infective endocarditis: a
propensity score analysis. Clin Infect Dis 2007; 44:364.
Cabell CH, Abrutyn E, Fowler VG Jr, et al. Use of surgery in patients with native valve infective
endocarditis: results from the International Collaboration on Endocarditis Merged Database. Am
Heart J 2005; 150:1092.
Tleyjeh IM, Ghomrawi HM, Steckelberg JM, et al. The impact of valve surgery on 6-month
mortality in left-sided infective endocarditis. Circulation 2007; 115:1721.