Endo-AAA and recent infective endocarditis.

[sevoflurane]

78 y/o male with dilated/ischemic cardiomyopathy with an EF of 20%, pacer dependent with sick sinus syndrome, PVD, 5cm AAA, Type 2 DM and COPD. 5 weeks ago he was found to be febrile with chills and weight loss. Positive for enteroccos faecalis cultures. Echo revealed mobile vegetative infective endocarditis on one of his pacer/ICD leads (right atrial lead 2cmX2cm). Subsequently his pacer was removed and replaced with a biventricular pacer/ICD. He has had 4 weeks of IV antibiotics and cultures and now negative. He is now scheduled for an endo-AAA. Cardiology note states high risk for peri-operative events.

Would any of you get a repeat echo to evaluate for vegetations despite negative cultures (sterile endocarditis in the setting of recent IV abx and new right sided pacer leads)? He is to have surgery exactly 5 weeks after the removal of his infected pacer/ICD.

My biggest fear is deploying a AAA stent that gets infected. This guy is even higher risk for open AAA.

Culture negative means no repeat echo? Just curious as to what others would do.

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[sevoflurane]

Pretend your hospital doesn't have any cardiologists to answer your question cuz all 10 of them are on vacation.... and the case is scheduled for tomorrow.

 

[Idiopathic]

78 y/o male with dilated/ischemic cardiomyopathy with an EF of 20%, pacer dependent with sick sinus syndrome, PVD, 5cm AAA, Type 2 DM and COPD. 5 weeks ago he was found to be febrile with chills and weight loss. Positive for enteroccos faecalis cultures. Echo revealed mobile vegetative infective endocarditis on one of his pacer/ICD leads (right atrial lead 2cmX2cm). Subsequently his pacer was removed and replaced with a biventricular pacer/ICD. He has had 4 weeks of IV antibiotics and cultures and now negative. He is now scheduled for an endo-AAA. Cardiology note states high risk for peri-operative events.

Would any of you get a repeat echo to evaluate for vegetations despite negative cultures (sterile endocarditis in the setting of recent IV abx and new right sided pacer leads)? He is to have surgery exactly 5 weeks after the removal of his infected pacer/ICD.

My biggest fear is deploying a AAA stent that gets infected. This guy is even higher risk for open AAA.

Culture negative means no repeat echo? Just curious as to what others would do.

This is not an anesthetic fear, though. I would deliver anesthesia for this patient, if requested, however I would be hesitant to fix a 5cm AAA electively. Even fully optimized without infection he sounds like a high risk for periop events (thanks cardiology!). MAC/local, +/- arterial line, epidural if not anticoagulated. magnet and defibrillator available.

I guess i just dont see how endocarditis without signs of heart failure would change your management. No severe TR, positional orthopnea, blowing murmur, new and worsening peripheral edema...

 

[sevoflurane]

This is not an anesthetic fear, though.

Yeah man... you are absolutely right. Just trying to do what's right for this patient... kinda stepping outside of the anesthesia shoes here. As far as I could tell, there are no fixed guidelines in regards to F/U echo in this situation. Unfortunately, I have a coupla surgeons at my place who completely disregard patients safety with regards to optimization and surgical/anesthesia risks... and I almost never cancel cases.

FWIW, this guy goes in and out of CHF all the time, has chronic peripheral edema, cr. of 1.7 (and you know he’s gonna get some dye during an Endo-AAA).

 

[sevoflurane]

I guess i just dont see how endocarditis without signs of heart failure would change your management.

Right again... it wouldn't change my intra-op management. However, if I saw active endocarditis on the echo, I'd have a sit down with the vascular surgeon and discuss the benefits of further IV abx tx before deploying a stent that would be at risk for infection.

 

[dhb]

5cm AAA.

I'll take a pass; repairing a 5cm AAA in this guy?? Let someone else be the hero...

but i guess if he has 3 different sets of hemocultures that come back negative you can go ahead.

 

[nap$ter]

Infectious Disease Consult

And I'm with you - I would guess he needs an echo. I would like to know that there are no veggies sterile or not.

His daily risk for rupture at 5cm is tiny, but if his new graft gets infected it'll be the end for him. (although it sounds like the beginning of the end has already begun for this dude).

 

[Gasworks]

Fairly presumptuous to assume that the vascular surgeon doesn't care about his stent getting infected. How would you feel if he looked over the drapes and started telling you that you should be using Iso instead of Des? If he's got -ve cultures and is afebrile than you have no cause to delay this case with needless tests.

I'd be more concerned with making sure he got preop abx and B-blocker.. if anything to keep the SCIP nurse from calling me in for a meeting (this is a joke).

 

[sevoflurane]

In this day and age, all morbidities and mortalities are tracked and that data is reviewed on a yearly basis. All surgeons care about their patients and their complications. However, I believe a lot of us have worked with some providers that don't quite get anesthetic and surgical risk. My concern for this patient wasn't weather or not the stent can be deployed, but rather what happens to him if it gets infected. This is the type of open AAA patient that will make it out of the OR only to stay in the CVICU for 2 weeks skimming the top of the trees before his family finally decides to pull the plug. I've seen this over and over during training and here in PP. You have a great conversation with a patient who is to undergo a major procedure...next thing you know, they are having a long ICU stay that culminates in death. Happens to me a handful of times a year.

My particular case sort of reminds me of this story I heard at this years ASA meeting. The long and the short of it was that a 20 something y/o kid was involved in a horrific MVC. Suffered massive internal injuries, broken bones, ruptured vessels and organs... you guys know the type. He underwent 5ish months of ICU care and countless trips back to the OR before he was sent home. Among many of his injuries, he had a ruptured spleen for which it was removed. Well, the kid made a big comeback.... BUT a year later died of a pneumococcal pneumonia. The moral of the story is that there were so many physicians taking care of this individual that something as simple as a pneumococcal vaccine was not ordered because other services didn't really get together on such a simple subject as a vaccine. So it never was given, and after a long (and costly) hospital stay this kid died 2/2 to a preventable disease.

This story has stuck with me and I appreciate having heard it... now back to my patient:

I'm not trying to be presumptuous. I'm only trying to cover all the bases and am wondering what others would do with regards to this particular patient as their is no hard guidelines. Again, I rarely cancel cases... and I didn't on this one.

The case went well and without a glitch.

However, he's now growing enterococcus in his blood and I am reflecting on whether or not I should have obtained that echo... for which he is now going to get.

 

[Idiopathic]

I agree with your thoughts re:global management, but this is a challenging case, when you are torn between what you have been asked to do (care for the patient in the perioperative period - which assumes he WILL get the procedure) and whats best for the patient (probably not doing this case electively, REGARDLESS of whether there are negative cultures).

I dont think there is anything wrong with suggesting echo, but do you put the guy to sleep for a TEE if you cant see a veg on TTE? Does not having a valvular vegetation mean he wont get the graft infected? I think you can get the echo but Im not sure how sensitive it would be,

 

[sevoflurane]

I agree with your thoughts re:global management, but this is a challenging case, when you are torn between what you have been asked to do (care for the patient in the perioperative period - which assumes he WILL get the procedure) and whats best for the patient (probably not doing this case electively, REGARDLESS of whether there are negative cultures).

I dont think there is anything wrong with suggesting echo, but do you put the guy to sleep for a TEE if you cant see a veg on TTE? Does not having a valvular vegetation mean he wont get the graft infected? I think you can get the echo but Im not sure how sensitive it would be,

Exactly why there are no hard guidelines. Good response dude.
I'm also not sure how sensitive an echo would be in the setting of a month of IV abx and a new ICD/pacer which was exchanged around the same time the infected one was pulled out.
Probably not very, but I just don't know.
Dropping a TEE probe shortly after induction and before stent deployment might have been a good idea, I suppose.
Retroscope is always 20/20.

 

[dhb]

All surgeons care about their patients and their complications.

Weird cause this patient will die well before his aneurysm ruptures so what's the point of this procedure? This fact is much more important than the risk of infection imho...

 

[dhb]

78 y/o male with dilated/ischemic cardiomyopathy with an EF of 20%, pacer dependent with sick sinus syndrome, PVD, 5cm AAA, Type 2 DM and COPD. Positive for enteroccos faecalis cultures.

I mean come on how much does he have left in the tank???

 

[sevoflurane]

Weird cause this patient will die well before his aneurysm ruptures so what's the point of this procedure? This fact is much more important than the risk of infection imho...

Likely so, but that is a decision made between the patient and the surgeon. These endo-AAA's are butter... really revolutionized the morbidity associated with an open AAA.

So all in all, it seems that most people I've presented this case to would have elected to not get an echo as I did. However, it wasn't a unanimous decision... including a couple of cardiologists at my home institution.

Thanks for the comments folks. Enjoy the rest of the weekend.

 

[BLADEMDA]

Likely so, but that is a decision made between the patient and the surgeon. These endo-AAA's are butter... really revolutionized the morbidity associated with an open AAA.

So all in all, it seems that most people I've presented this case to would have elected to not get an echo as I did. However, it wasn't a unanimous decision... including a couple of cardiologists at my home institution.

Thanks for the comments folks. Enjoy the rest of the weekend.

The only part of this case that seems strange is the lack of f/u from cardiology. If you think a patient has any hint of infective endocarditis then a note from CARDS should be on the chart stating "all clear" and ready for his elective AAA stent.

I've got no problem placing an ECHO probe after my GA/ETT is underway but I'd rather not limit my anesthetic choice to an ETT. A few of my partners are doing these under LMA these days.

Of course, it isn't your job as an Anesthesiologist to be worried about an infected AAA stent post op but it is the right thing to do as his perioperative physician.

 

[sevoflurane]

The only part of this case that seems strange is the lack of f/u from cardiology. If you think a patient has any hint of infective endocarditis then a note from CARDS should be on the chart stating "all clear" and ready for his elective AAA stent.

Cards deemed him "high risk" and had then signed off weeks earlier to Infectious disease who then "cleared" him based on 4 weeks of IV abx.

A few of my partners are doing these under LMA these days.

Ditto...

I'm not there yet as it's easier to hold breaths with an ETT in place.

For those interested in reading up on culture negative endocarditis here is a quick and fun little case report with a couple of pics + review of the modified Dukes criteria.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1767573/

"In most cases, there are two reasons for negative blood cultures: (1) patients received antibiotics before blood cultures are taken due to systemic infection or suspected diagnosis of a bacterial infection; and (2) the causative microorganisms have no, or limited proliferation in conventional blood cultures, or the diagnosis of the causative microorganisms requires special media or cell culture conditions. Negative blood cultures occur in 2.5–31% of all cases of infective endocarditis, which often delays diagnosis and onset of treatment with profound impact on the clinical outcome. The difficulties arising from culture negativity in cases of suspected endocarditis may be illustrated by a recent example from our institution."

In people who do not get previous antibiotics, culture negative endocarditis is usually due to Coxiella, Bartonella or Chlamydia species.
This is differen than libman-sacks endocarditis that you see with SLE (immune complexes).... which also won't grow anything.

 

[BLADEMDA]

The above case illustrates that echocardiography can provide crucial diagnostic information. In fact, transoesophageal echocardiography appears essential for the diagnosis of culture negative endocarditis when the Duke criteria are applied.7