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2015 GUIDELINES Source

  • Baddour LM, Wilson WR, Bayer AS, et al. Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association. Circulation. 2015;132:1435–1486.

  • Echo is central to diagnosis and management.

  • Echo findings may suggest a need for surgical intervention.

  • Recommendations are made for initial and repeat echo imaging.

European Guidelines Source
  • Habib G, Hoen B, Tornos P, et al. Guidelines on the prevention, diagnosis, and treatment of infective endocarditis: The Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of the European Society of Cardiology (ESC). Eur Heart J. 2009;30:2369–2413.

  • Extensive document covering all clinical aspects of endocarditis.

DISEASE OVERVIEW

  • Endocarditis is caused by, and accompanied by, bacteremia or fungemia.

  • The echocardiographic hallmark is a vegetation.

  • Microorganisms attract blood fibrin and platelets to form the vegetation.

Source

  • Cahill TJ, Baddour LM, Habib G, et al. Challenges in Infective Endocarditis. J Am Coll Cardiol. 2017;69:325–344.

  • Location of vegetations:

    • - Most commonly attached to the surface of native valve leaflets.

    • - May attach to mitral or tricuspid chordae.

    • - Difficult to localize and diagnose on prosthetic valves.

  • Pacemaker/ICD wires may have to be completely removed if they become infected.

  • Congenital heart defects and congenital defect repairs may become infected.

  • The point of attachment varies, but there are some useful typical echo features.

  • Vegetations are said to favor the upstream side of valves: Atrial side of mitral and tricuspid valves, and ventricular side of aortic valves (pulmonic valve endocarditis is rare).

  • The usual appearance is a shimmering, shaggy, stippled, pedunculated mass.

  • Reflectivity and texture are typically similar to normal myocardium.

  • Calcification suggests chronicity.

Source

  • Kini V, Logani S, Ky B, et al. Transthoracic and transesophageal echocardiography for the indication of suspected endocarditis: vegetations, blood cultures, and imaging. J Am Soc Echocardiogr. 2010;23:396–402.

  • Complications:

    • - Leaflet perforation.

    • - Abscess.

    • - Fistula.

    • - Embolism.

Sources

  • Anguera I, Miro JM, Vilacosta I, et al. Aorto-cavitary fistulous tract formation in infective endocarditis: clinical and echocardiographic features of 76 cases and risk factors for mortality. Eur Heart J. 2005;26:288–297.

  • Sudhakar S, Sewani A, Agrawal M, et al. Pseudoaneurysm of the mitral-aortic intervalvular fibrosa (MAIVF): a comprehensive review. J Am Soc Echocardiogr. 2010;23:1009–1018.

  • Thuny F, Disalvo G, Belliard O, et al. Risk of embolism and death in infective endocarditis: prognostic value of echocardiography. A prospective multicenter study. Circulation. 2005;112:69–75.

  • Clinical suspicion:

    • - Persistent fever.

    • - Fever with a new murmur.

    • - Change in an existing murmur.

    • - Conduction abnormality on ECG.

    • - Embolic event.

    • - Newly diagnosed dehiscence on echo of an existing prosthetic valve.

    • - New heart failure is an ominous finding and justifies surgical intervention.

  • Differential diagnosis:

    • - Calcification.

    • - Lambl excrescences.

    • - Libman-Sacks.

    • - ...

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