Preface

**Section 4 Special Problems 119**

**VI** Contents

Stawicki

Chapter 7 **Infective Endocarditis in End-Stage Renal Disease Patients in Developing Countries: What is the Real Problem? 121** Díaz-García Héctor Rafael, Contreras-de la Torre Nancy Anabel, Alemán-Villalobos Alfonso, Carrillo-Galindo María de Jesús, Gómez-Jiménez Olivia Berenice, Esparza-Beléndez Edgar, Ramírez-Rosales Gladys Eloísa, Portilla-d Buen Eliseo and Arreola-Torres Ramón

Chapter 8 **Septic Embolism: A Potentially Devastating Complication of**

Thomas R. Wojda, Kristine Cornejo, Andrew Lin, Anthony Cipriano, Sudip Nanda, Jose D. Amortegui, Barbara T. Wojda and Stanislaw P.

**Infective Endocarditis 143**

Endocarditis, by definition, represents an infection of the heart or, more specifically, the valves or intracardiac structures. The diagnosis and management of these complex infec‐ tions have challenged clinicians for years—and despite significant advances, they continue to do so. The physiologic consequences of not only systemic sepsis from the bacteremia but sometimes, more importantly, also the associated acute congestive heart failure from in‐ volvement of the cardiac valves can be difficult to manage and potentially catastrophic in presentation. Overwhelming infections can also result in intracardiac fistulae with shunting and arrhythmias that can be difficult to manage and often are indications for emergent inter‐ vention. Coronary embolisms of infected material can further cloud the clinical picture as patients may present with signs and symptoms of an acute myocardial infarction. Neverthe‐ less, there have been significant improvements in the initial diagnosis and management of these problems. A greater awareness of the presentations of sepsis and the recognition that a substantial subset of patients with complex comorbidities may have associated endocarditis have contributed to the greater recognition and incidence of this diagnosis. Furthermore, advances in diagnostic testing have allowed for more specific identification of causative agents as more and more patients present with polymicrobial infections, fungal infections, drug-resistant organisms, and even atypical or culture-negative endocarditis from noninfec‐ tious sources.

Without a doubt, the growing spectrum of comorbidities that patients present with places them at increased risk for developing these catastrophic infections. The dramatic increase in substance abuse, especially heroin and synthetic drugs, has also resulted in a significant in‐ crease in younger patients presenting with complex cardiac infections. Often, patients be‐ cause of their physiologic reserve may not present until late in their clinical course with extremely challenging cardiopulmonary problems with potentially devastating septic embo‐ li. Their socioeconomic and compliance problems combined with the mental health issues that are associated with drug abuse make this population extremely difficult to manage suc‐ cessfully both short term and long term. In addition, the growing use of intravascular and cardiac support devices such as pacemakers, defibrillators, left ventricular assist devices, in‐ travascular ports, and long-term monitoring devices places patients at increased risk for in‐ fections that can be difficult to manage. Greater access to cardiac surgery with more patients getting either surgical or percutaneous valve procedures has also resulted in an increased incidence of infections. Furthermore, as patients develop more problems that historically might have limited their life span, combined with the growing use of immunomodulating medications for a variety of disorders, there is also an inherent increase of the risk for all types of infections—including endocarditis. It is becoming better understood that these pop‐ ulations, such as those with end-stage renal disease, require a greater index of suspicion

with aggressive and timely evaluation and management at the first signs of a potential infec‐ tion. Fortunately, with greater access to diagnostic testing and appropriate antimicrobial therapy, the prognosis has improved over the years. Most significantly, it has been the rec‐ ognition that early surgical intervention in appropriately selected patients also substantially improved the short- and long-term outcomes.

Endocarditis represents one of the few areas of medicine that require an aggressive and timely response by a multidisciplinary team. The spectrum of problems and presentation of patients require a rapid response to determine an effective care plan. Such plans must be open to reevaluation continuously as the clinical course can be difficult to predict. Good team communication cannot be overemphasized. As guidelines and protocols continue to evolve and assist in patient management, the variability in disease presentation requires each case to be individualized. While a single text on this topic would be overwhelming, the hope of this book is to highlight and provide modern insight into some of the current chal‐ lenges and controversies that impact patient care directly.

#### **Michael S. Firstenberg, MD FACC**

Associate Professor of Surgery and Integrative Medicine Northeast Ohio Medical Universities Akron City Hospital - Summa Health System Akron, Ohio, USA

**Section 1**
