MARIVIC MOTILLA-ESGUERRA, MD

PEDIATRIC CARDIOLOGIST, ECHOCARDIOGRAPHER

 1. To know the different acquired heart
diseases
o To know the etiology of acquired heart diseases
o To know the pathophysiology of acquired heart
diseases
o To know the management acquired heart
diseases

 Agent Frequency
Streptococci Responsible for most
- hemolytic most common Cases of IE in all age
-hemolytic uncommon groups
Enterococci rare
Pneumococci rare
Others uncommon
Staphylococci
S. aureus second most common
coagulase-negative uncommon, but increasing
Gram-negative agents <10% of IE in children
Enterics rare Neonates, immunocompromised,
IV drug abusers are at inc risk
Pseudomonas species rare Most feared
HACEK rare Affect previously
Embolization damaged
is frequent
Neisseria species rare Valves
In narcotic addicts, or after
Fungi Cause
Cardiacsubacute
surgery,course
neonates and
Frequently results in emboli
Immunocompromised pts.
Candida species uncommon Mortality rate is high
Others rare
 COMMON: NATIVE VALVE OR OTHER CARDIAC LESIONS
Viridans group streptococci (S. mutans, S. sanguis, S.
mitis)
Staphylococcus aureus
Group D streptococcus (enterococcus) (S. bovis, S.
faecalis)

 Streptococcus pneumoniae
Haemophilus influenzae
Coagulage-negative staphylococci
Coxiella burnetii (Q fever)[*]
Neisseria gonorrhoeae
Brucella[*]
Chlamydia psittacli[*]
Chlamydia trachomatis[*]
Chlamydia pneumoniae[*]
Legionella[*]
Bartonella[*]
HACEK group[]
Streptobacillus moniliformis[*]
Pasteurella multocida[*]
Campylobacter fetus
Culture negative (6% of cases)
 Staphylococcus epidermidis
Staphylococcus aureus
Viridans group streptococcus
Pseudomonas aeruginosa
Serratia marcescens
Diphtheroids
Legionella species[*]
HACEK group[]
Fungi[]
Pre-existing congenital/acquired heart disease

Pressure gradient turbulence

tissue damage microorganisms

fibrin / platelet adherence Nidus of infection

lysosomal granules release

hydrolytic enzymes
 Finding Frequency
Clinical
Fever ++++
Non-specific symptoms (myalgia,
arthralgia, headache, malaise) +++
Heart murmur (new or changing) ++
Heart Failure ++
Petechiae ++
Embolic phenomena ++
Splenomegaly ++
Neurologic Findings ++
Osler nodes, Janeway lesions,
Roth spots, splinter hemorrhages +

Legend:
++++ very common ++ infrequent
+++ in most cases + rare
 Finding Frequency

Laboratory
Positive blood culture (off antibiotics) ++++
Elevated acute phase reactants ++++
Anemia +++
Hematuria +++
Presence of rheumatoid factor ++
Leukocytosis ++

Legend:
++++ very common
+++ in most cases
++ Infrequent
+ rare
 new or changing murmurs are usually heard
- Frequent auscultation is essential
Patients with suspected embolic events are
candidates for serial echo to localize vegetations
and to define changes that may occur with time
Splenomegaly may be present in a majority of
instances when the disease has been present for
weeks or months
Neurologic findings are present in 20% of children
and may simulate the picture of an abscess,
infarct or aseptic meningitis
 most valuable tool
Collection of 2 or 3 samples over a 24 hr period is adequate in
most cases

Acute phase reactants are elevated

ESR only minimally elevated (as the disease progresses , the
ESR will increase)
- remain elevated for some time even after documented
bacteriologic cure

Immune complexes or Rheumatoid factor

Anemia common, particularly in long standing infection
May be hemolytic or may represent anemia of chronic
disease

Microscopic or macroscopic hematuria represents renal

embolization or nephritis

Leukocytosis is not a consistent finding but is more common in

acute IE

Antibodies against techoic acid and cell wall peptidoglycan in

severe staphylococcal infection may be present
A negative echocardiogram does not rule out
endocarditis
More helpful in children with normal cardiac
anatomy or with isolated valvar abnormalities in
children with more complex congenital anomalies
Duke Major Criteria : oscillating intracardiac mass
or vegetation, an annular abscess, prosthetic valve
partial dehiscence, and new valvular regurgitation
DIAGNOSIS

o (+) blood culture
o Evidence of endocarditis on echocardiography
A. Positive echocardiogram for IE defined as:
i. Oscillating intracardiac mass on valve or supporting
structures, in the path of regurgitant jets, or an implanted
material in the absence of an alternative anatomic
explanation or
ii.Abscess, or
iii.New partial dehiscence of prosthetic valve or
B. New valvular regurgitation (worsening or changing of
preexisting murmur)
 Minor criteria
Predisposition: predisposing heart condition or intravenous drug use

Fever: temperature > 38.0 C (100.4 F)

Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic

aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway lesions

Immunologic phenomena: glomerulonephritis, Osler's nodes, Roths spots and

rheumatoid factor

Microbiological evidence: positive blood culture but does not meet a major criterion
as noted above or serological evidence of active infection with organism consistent
with IE

Echocardiographic findings: consistent with IE but do not meet a major criterion as

noted above
Excludes single positive cultures for coagulase-negative staphylococci, diphtheroids,
and organisms that do not commonly cause endocarditis.
2 major criteria or
1 major and 3 minor criteria or
5 minor criteria
 Heart failure-mitral and aortic valve
Myocardial abscess and toxic myocarditisArrhythmias
Systemic emboli
Pulmonary embolism VSD TOF
mycotic aneurysms
rupture of a sinus of Valsalva, obstruction of a valve
secondary to large vegetations, acquired VSD, and heart
block as a result of involvement (abscess) of the conduction
system.
meningitis, osteomyelitis, arthritis, renal abscess, and
immune complexmediated glomerulonephritis.
 AHA Guideline 2008
Prophylactic regiments for dental, oral, or respiratory tract , procedures

Agents Regimen (single dose 30-

60min before procedure)

Standard oral prophylaxis Amoxycillin 50 mg/kg p.o. (max 2 g)

Unable to take oral medications Ampicillin or 50 mg/kg IM/IV(max2g)

Cefazolin or ceftriaxone 50 mg/kg IM/IV (max1g)

Penicillin allergic-oral regimen

Clindamycin or 20 mg/kg (max 600 mg)
Cephalexin a or 50 mg/kg (max 2 g)
Azithromycin or clarithromycin 15 mg/kg (max 500 mg)

Penicillin allergic and unable to take

oral medication Clindamycin
or 20 mg/kg IV (max 600 mg)
Cefazolin a 50 mg/kg IM/IV(max 1g)

aCephalosporins should not be used in individuals with immediate-type hypertensivity reaction (urticaria,
angioedema, or anaphylaxis) to penicillins.

Definition:
An auto immune disease preceded by GABS
Generalized disease affecting all the connective tissues of
the body
Characterized by periods of exacerbation
Commonly affects 6-15 years old
Major Criteria
1. Arthritis
2. Carditis
3. Erythema Marginatum
4. Subcutaneous nodules
5. Chorea
 Minor Criteria
Clinical Laboratory
Fever
ASO
Arthralgia (joint
ESR
pains w/o CRP
objective WBC
findings) pr interval
2major
1major + 2minor
 Mitral valve insuficiency
pathophysiology

Clinical
manifestation

complications
 Mitral valve stenosis
pathophysiology

Clinical
manifestation

complications
 Aortic Insufficiency
pathophysiology

Clinical
manifestation

complications
 Tricuspid Insufficiency
pathophysiology

Clinical
manifestation

complications
pulmonic Insufficiency

 Diseases of the myocardium
primary vs. secondary
Classification:
o Dilated
o Hypertrophic
o Restrictive

 Accumulation of fluid in the pericardial space
Tamponade
Clinical Manifestations
o Precordial pain- sharp, stabbing pain radiating to the Left shoulder and
back
o Friction rub
o Pulsus paradoxus
Diagnosis
o Echocardiogram
o ECG
Low voltage QRS
T wave inversion
Electrical alternans

Constrictive pericarditis