Endocarditis

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Ryanvs

Well-known member
Joined
Jan 10, 2016
Messages
116
Location
Newcastle, New South Wales, Australia
Ive tried to do some research online, but I haven't found the answer so maybe some here can explain something to me.

Both my surgeon and cardiologist stressed the importance of maintaining good oral hygiene to help prevent infection that could lead to endocarditis. They explained the risks and problems that can occur with patients that have mechanical valves.

What im just curious about is, are the chances of getting endocarditis increased due to having an AVR, or does it simply lead to more complications (chance of reop etc) when compared to someone who hasnt undergone an AVR.

Just curious.
 
Hi
Ryanvs;n869689 said:
Ive tried to do some research online, but I haven't found the answer so maybe some here can explain something to me.
I expect that why you aren't finding much on line is because noone has done any definitive research. I expect the reasons for this are many fold, like: noone is paying for it, noone of sufficient interest and ability has time (because someone is paying them for something else) no one feels that it is knowledge that brings much with it (such as prevention), it doesn't effect many people ...

So with that in mind what follows is my conjecture (which by the way I've passed by a few people who are smarter / more specifically educated / older than me.

Basically your blood vessels (and your heart) are lined with a layer of cells called endothelia. These cells essentially make the surface of your tubes rather non stick (among other functions) like a non-stick pan, so as you can imagine cutting through the aorta to replace the valve causes disruption just like any scar you may get on your skin. This alters the smooth surface (think dolphin skin) that is beautifully designed to be hydraulically smooth too, to being rough and may have surface irregularities or lumps. Tto go with that earlier metaphor making a place on the pan where stuff sticks more easily.

Certainly endothelia grow back (even on the inside of the dacron graft in an aneurysm repair) but now the surface is poc marked and irregular which makes it much easier for bacteria to lodge and grow.

Now the endothelia don't have a role in the destruction of bacteria, only in the first level of protection, its the white blood cells that have that role. It could be that the damage to the endothelia is a bit trench or crater like (at a microscopic level) and that allows the bacteria to grow in a 'vegetative" manner and prevents the white blood cells from entirely defeating them.

Many bacteria are called opportunistic and so when the body is busy fighting one thing the other has a chance to grow.

This is why not only valve replacement patients (and to my knowledge there is no difference discovered in tissue VS mechanical prosthesis for rates of endo) but also people who have had diseases (like scarlet fever) may have their endothelia in their heart damaged and even their valve tissue surfaces scarred leading to them also being more likely to get endo than the general population.

The stress on oral hygene (which is often stressed but no actual education on how to attain that is given) is correct because in the general population mouths are festeringly filthy places. If ever you've had to take a step back from someone with rancid rotting breath that's because their mouth is thousands of times more infested than normal. The society at large knows nothing about bacteria and mis-interprets bad breath or bleeding gums as something unique to them (like their height or their hair colour) and something which can be covered up. It is in fact a clue to how infested your mouth is with growing things.

Thus its good to sit down and talk openly with your oral hygienist about how to floss properly and how to keep your mouth from becoming a bacterial playground. gingivitis in a mild form can be mistaken by a person (not a dentist) for "sensitive gums" ... its actually an indicator of plaque build up which is essentially the "coral reef on your tooth" that bacteria build up to live in , just like the marine coral polyps do on rocks.

I hope that helps.
 
lol Agian, It must be important as I am rinsing mouth twice daily with Peridex per pre-surgery dental visit. Great explanation.
 
Agian;n869711 said:
They say eating dog **** will do it too.

I just remembered that a friend of mine found this not to be true with cat ****.

He had a sand pit for his kid when he was about 3 and one day noticed Mackie was often appearing to eating things when playing in the sand pit. Anthony thought it was sand, till he spotted it was something black. He fished it out of his mouth and found it was cat poop.

From then on a cover was put over it when they weren't using it :)
 
I might as well be eating dog ****, with the staining those mouthwashes cause.
I don't lose sleep over it, being a fella, but I've got brown discolouration on my teeth.
 
Agian;n869738 said:
I might as well be eating dog ****, with the staining those mouthwashes cause.... but I've got brown discolouration on my teeth.

Red wine and coffee does most of it for me :)
 
Agian;n869738 said:
I might as well be eating dog ****, with the staining those mouthwashes cause.
I don't lose sleep over it, being a fella, but I've got brown discolouration on my teeth.
Do you use Corsodyl or a make with chlorhexidine in it ? I was given that post extraction once but both doctor and dentist said to only use it for a few weeks. Oral hygenist at dentist also says that. I think the mouthwashes that are free of chlorhexidine and alcholol are the ones recommended for long term daily use and they don't stain teeth. Floss, brush, interdental brush, to get rid of the plaque that the 'bad' bacteria like, and diet free of things the pesky ones like - if you can encourage colonies of 'good' bacteria that will help teeth and gums.
 
Cetylpyridium is what is in mine, Cepacol brand minty whatever. It also has alcohol in it.
My dental hygienist is very anti-mouthwash. I'm in deep trouble when she sees my teeth.
I rinse, wait 5 minutes, brush, rinse, floss, rinse (eyes roll).
Could be the wine, which I'm having as we speak.
 
I have wine every evening but I think the stains I get on my teeth are due to tea and coffee - they're not too bad, but I rinse with water after every time I have tea or coffee. My hygienist says that some people's teeth stain more easily than other people's. I don't use mouthwash.
 
In regards to the original posted question about the increased risk for endocarditis following AVR/MVR, and in addition to Pellicle' reasoning, I would like to add that at least some of the risk is a result of the unnatural blood flow dynamics that are present following these surgeries. The slight pooling up of blood that occurs in the left atrium (MVR) or the left ventricle (AVR) as the blood flows through the replacement valves give the bacteria a chance to attach and grow. This is the same reason why people with a heart murmur are at increased risk for endocarditis (which is what got me) even though the AMA and ADA no longer seem to think so given the fact that they no longer recommend antibiotics prior to dental work. An additional reason for the AVR/MVR risk, I have been told, is that because there is no blood inside of these valves they lack the infection fighting abilities of the native valves. Not so sure about this last one.....
 
Hi QuincyRunner, thank you for your input. I had actually read somewhere something similar to what you've said above (especially the last part about "no blood inside of these valves they lack the infection fighting abilities of the native valves") however, I actually couldn't remember/find where I read it (it read it before I had my AVR surgery) and other documentation I had read since didn't mention this point.
 
Hi

QuincyRunner;n869748 said:
In regards to the original posted question about the increased risk for endocarditis following AVR/MVR, and in addition to Pellicle' reasoning, I would like to add that at least some of the risk is a result of the unnatural blood flow dynamics that are present following these surgeries. The slight pooling up of blood that occurs in the left atrium (MVR) or the left ventricle (AVR) as the blood flows through the replacement valves give the bacteria a chance to attach and grow.


good point! I expect that the ejection fraction issue compounds with stenosis to create some eddy currents behind the valve which no longer collapses properly.
 
Hi

Ryanvs;n869750 said:
... I had actually read somewhere something similar to what you've said above (especially the last part about "no blood inside of these valves they lack the infection fighting abilities of the native valves") however, .

I think that he is correct, and that the valve tissue itself is not vascularised. But then neither is the surface of your skin isn't either. There are all manner of things living in and on that but I think that its the exfoliation of your skin surface which stops that from getting out of control. But as we know there are things which grow on the skin (fungi for instance) that are dreadfully difficult to shift.

Thinking about it the tissue would not need to be vascularised to remain living, because it has a ready supply of blood all around it all the time :) So while it is not vascularised I don't believe that the cells are "dead tissue" as your skin surface is. I wonder if this itself would be an indicator of onset of valve disease were we able to actually check the tissue.

A bit of research seems to suggest my above guess is correct:
Vascularization of the valve is not necessary because the cusps are thin enough for oxygen, nutrients, and waste to diffuse between the tissue and the surrounding blood.

cited from: :
http://circres.ahajournals.org/content/113/2/186


its quite an educational read ....

Aortic Valve Cells

The aortic valve tissue architecture is synthesized and maintained by the resident valvular interstitial cells (VICs).2,5 In the healthy adult valve, VICs are largely a quiescent fibroblast phenotype, with a minor (<5%) population of myofibroblasts and smooth muscle cells.13&#150;17During development, on valve injury, and with disease, VICs can be activated to a secretory myofibroblast phenotype.18 A potent activator of the VICs to the myofibroblast phenotype is transforming growth factor-β1 (TGF-β1),18&#150;23 an inflammatory cytokine that is present in diseased valves.24 The hallmark indicator for an activated myofibroblast is α-smooth muscle actin (αSMA) stress fibers within the cytoskeleton.25 Activated VICs perform many functions to promote valve repair and homeostasis, including proliferation18,21,26 and secretion of cytokines such as TGF-β1,19 matrix metalloproteinases,18,19,21,27 and ECM molecules.18,21,22,27,28 In addition to myofibroblasts, diseased valves contain osteoblast-like cells and other ectopic mesenchymal cells29&#150;31; these cells are likely derived primarily from resident mesenchymal progenitor cells,32 although endothelial-to-mesenchymal transformation33 and circulating progenitor cells34,35 may also contribute.

so it seems that there is a repair / regeneration mechanism in valve material (my underlined). I wonder if there is currently any testing procedure on this which does not involve removal of the valve?
 
I guess getting infective endocarditis (IE) makes me the expert, and I only had a mitral valve repair. Yes taking 2000 mg amoxicillin for dental is pretty standard for me. Also, same dose for surgeries, for example, hernia in my case. Also colonoscopies. I had a strep strain F and my ID doctor and cardiologist have no answer as to how I may have gotten it. And since I had it once, I can get it again. Only difference now is that my plan includes getting a blood culture if fever lasts more than 6 hours or so and don't take meds for the fever until I get my blood culture. Somewhat inexact, but I assure you very stressful.

PS. My truly natural valve was not compromised and my regurg remains mild. However, a piece of vegetation less than 5mm shot to my leg and resulted in an emergency popliteal arterial thrombectomy and 3 compartment fasciotomy. Yes that ****ed.
 
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