Current diagnosis and treatment of infective endocarditis

The incidence of infective endocarditis continues to rise with a yearly incidence of around 15,000 to 20,000 new cases in the USA. As a result, rapid diagnosis, effective treatment and prompt recognition of complications are essential to desirable clinical outcomes. Recent guidelines such as the Duke criteria have incorporated echocardiography for diagnosis of infective endocarditis, making this diagnostic test mandatory for patients with suspected infective endocarditis. The diversity of pathogens that can cause infective endocarditis, some of which cannot be cultured easily, makes diagnosis even more difficult. Coagulase-negative staphylococci and viridans streptococci groups continue to be the major causative microorganisms of infective endocarditis. In the case of culture-negative endocarditis or infective endocarditis caused by fastidious microorganisms, the polymerase chain reaction and probe-based diagnostic methods are available to clinical reference laboratories.     

经胸超声心动图对感染性心内膜炎严重并发症的诊断价值和术后疗效评价

目的探讨经胸超声心动图在感染性心内膜炎严重并发症诊断及术后疗效评价中的应用价值。方法分析512例感染性心内膜炎中32例严重并发症,包括脓肿、膨出瘤、假性动脉瘤、假性室壁瘤或房壁瘤以及窦道或心腔间交通和赘生物脱落栓塞的超声心动图表现及临床特征,并与手术结果对照;赘生物脱落栓塞3例同时与多排CT对照。结果 32例中31例与手术结果完全相符,经胸超声诊断符合率为96.9%。1例误诊(1/32),手术证实为主动脉窦瘤破裂入左心室。超声诊断栓塞3例,均经多排CT检查证实。结论经胸超声心动图能及时、快速、准确的诊断感染性心内膜炎的严重并发症,指导临床治疗,改善预后,并在术后疗效随访中有重要价值。     

感染性心内膜炎的超声诊断及临床价值

目的：探讨超声诊断感染性心内膜炎的临床价值。方法：总结11例经手术证实的感染性心内膜炎术前超声心动图资料，并与术中资料进行对比。结果：超声心动图对赘生物的大小、位置及数量的判断与术中基本一致，且超声心动图还可发现心脏有无基础病变及感染性心内膜炎导致的血流动力学异常。结论：超声心动图对感染性心内膜炎赘生物能进行准确定位，并确定其数目、大小及伴随的心脏病情况，为临床诊断及治疗提供可靠信息。     

62例感染性心内膜炎外科治疗临床分析

目的总结感染性心内膜炎外科治疗的临床经验,更好地指导临床工作中诊断和治疗。方法回顾性分析62例经外科手术治疗的感染性心内膜炎患者临床资料。结果术后55例治愈出院,随访3个月～5年,无复发,心功能（NYHA）恢复I～II级;术后住院时间死亡7例。结论感染性心内膜炎早期诊断、适时手术,术中无菌操作和彻底清除赘生物、矫治心内畸形或病变,术后合理应用抗生素,是成功治疗感染性心内膜炎的关键。     

经胸超声诊断感染性心内膜炎瓣膜赘生物形成

目的探讨感染性心内膜炎心脏瓣膜赘生物的超声声像图特点及诊断价值。方法应用经胸超声心动图观察心脏瓣膜赘生物的形态、大小、回声、分布及其瓣膜损害情况，对28例感染性心内膜炎心脏瓣膜赘生物进行超声诊断。结果超声心动图对赘生物的大小、位置及数量的判断与手术所见基本一致，同时还能对心脏有无原发病变及继发新血流动力学改变进行探查和判断。结论经胸超声心动图对感染性心内膜炎赘生物形成的诊断、定位、治疗决策及预后判断有重要的临床意义。     

活动期感染性心内膜炎手术时机的分析

目的 探讨活动期感染性心内膜炎(infectiue endocarditis,IE)患者心脏手术的最佳时期.方法 回顾分析1999年9月-2009年9月行外科治疗的92例IE患者的临床资料.IE诊断标准为修订的Duke标准.采用SPSS 12.0软件包,分析了年龄、性别、是否是院内感染IE、合并症(糖尿病、慢性阻塞性肿...     

Analysis of clinical background in patients with vegetation-like echoes: importance of clinical information

Purpose Detection of vegetation is important for diagnosing infective endocarditis.Methods We analyzed clinical information from 58 patients with vegetation-like echoes on transthoracic echocardiography who had been referred to this institution for an echocardiographic examination during the past 5 years. Patients with healed vegetations were excluded. A vegetation-like echo was defined as a mass, a thread-like echo attached to the valve or endocardium, or both. Diagnosis of a vegetation-like echo required the concurrence of two cardiologists and one sonographer. Altogether, 44 patients were treated with antibiotics because their clinical courses were consistent with active infective endocarditis.Results Blood cultures were positive in 27 patients and negative in 17 patients. Follow-up data were available for 10 of the 14 patients who had no findings suggestive of active infective endocarditis. The size of the vegetation-like echo remained unchanged over a mean interval of 12.1 months, and no clinical signs or symptoms of active infective endocarditis appeared. In about one-fourth of the patients with a vegetation-like echo, it was not associated with infective endocarditis.Conclusion Clinical information, in addition to detection of a vegetation-like echo, appears to be indispensable for diagnosing infective endocarditis.This article is a translation of the original that was published in Jpn J Med Ultrasonics 2001;28:J35–40     

超声心动图对感染性心内膜炎患者的赘生物及其他常见并发症的研究

目的总结和探讨感染性心内膜炎患者的赘生物及其他常见并发症的超声心动图详细特征及其不足之处。方法选取2003～2008年在我院住院且确诊为感染性心内膜炎患者118例,所有患者均进行了手术和病理检查确诊。并将患者经胸超声心动图与手术、病理结果进行比较研究。结果在符合入选条件的118例感染性心内膜炎患者中,病理发现赘生物或菌落者78例,慢性瓣膜炎71例,黏液样变性13例。本组病例中,超声检查出赘生物大小2～26mm,1至多个,活动度主要为好,以强或中强回声,首先以左心房面受累;超声心动图对赘生物检出率为83.8%;并且经胸超声心动图的检出率随着赘生物增大和数量逐渐增加。超声对于赘生物形态描述主要为团块状、不均质样回声,而手术中常描述为菜花状、结节状。超声对损伤瓣膜的检出率达89.1%,对单纯主动脉瓣损伤的检出率最高;对于其他并发症的检出率如人工瓣瓣周漏、瓣膜脱垂、脓肿、假性动脉瘤、瓣叶穿孔分别为100%、95.0%、66.7%、66.7%及33.3%,虽然超声对瓣叶穿孔检出率最低,但其特异度高达99.1%,而敏感度仅为22.2%。结论超声心动图能够对大部分感染性心内膜炎患者的赘生物大小、数量及附着位置、损伤瓣叶及其常见并发症进行准确判断,但对瓣叶穿孔判断能力有待提高,对赘生物形态的描述有待与手术统一。     

先天性心脏病合并感染性心内膜炎30例诊治分析

目的:探讨先天性心脏病合并感染性心内膜炎的诊断及治疗。方法:回顾性分析30例先天性心脏病合并感染性心内膜炎患者的临床特点、手术时机、手术方法及疗效。结果:本组治愈率90%,病死率10%;术前1例死于脑栓塞,术后早期死亡2例分别死于心力衰竭和脑出血;术后随访3个月~5 a,心功能恢复良好。结论:先天性心脏病不明原因发热>1周应考虑感染性心内膜炎;掌握手术时机,选择合适术式,结合围手术期抗感染治疗可提高治愈率。     

Enterococcus faecalis infective endocarditis: focus on clinical aspects

Enterococcus faecalis infective endocarditis (IE) is a disease of increasing importance, with more patients infected, increasing frequency of health-care associated infections and increasing incidence of antimicrobial resistances. The typical clinical presentation is a subacute course with fever, malaise and generalized aches, difficult to distinguish from other more common diseases. Of paramount importance is transthoracic- and transesophageal-echocardiography to establish the diagnosis. At the moment, the predominant strategies recommend ampicillin in combination with either gentamicin or ceftriaxone. E. faecalis infective endocarditis continues to be a very serious disease with considerable percentages of high-level gentamicin resistant strains and in-hospital mortality around 20%. Strategies to prevent E. faecalis IE, improve diagnostics, optimize treatment and reduce morbidity will be necessary to improve the overall prognosis.     

Infective endocarditis and osteomyelitis caused by Cellulomonas: a case report and review of the literature

Cellulomonas spp. are often believed to be of low virulence and have never been reported as a pathogen causing human disease before. We report the first case of endocarditis caused by Cellulomonas and complicated with osteomyelitis of the lumbar spine in a 78-year-old woman. General weakness and aggravated lower back pain followed by sudden-onset of fever and chills were the major presentation. The diagnosis of infective endocarditis in this case was definitely using the Duke criteria. The magnetic resonance imaging of the lumbar spine revealed infective spondylodisciitis at an early stage. After a full course of antibiotics treatment, the patient's fever subsided but her lower back pain persisted. A slow clinical response to appropriate antimicrobial agents was characteristic of Gram-positive bacillary endocarditis.     

超声心动图诊断感染性心内膜炎的临床价值

目的 评价超声心动图在感染性心内膜炎(infective endocarditis，IE)诊断中的价值。方法 分析总结38例IE患者的临床和超声心动图资料。结果 IE多发生于原有器质性心脏病基础上，以风心病和先心病为主。赘生物有附着位置、大小、形态及随病程变化多种超声特点。超声心动图可检出瓣膜脱垂、腱索断裂和瓣周脓肿等心脏内并发症。结论 超声能为临床提供IE患者的基础心脏病因、诊断、鉴别诊断、指导治疗和判断预后等具有重要价值的信息。     

感染性心内膜炎的诊治

目的：介绍对感染性心内膜炎的及时诊断和治疗选择的体会，方法：根据症状，体征，血培养，心脏超声等综合分析。做出诊断，分别进行手术及药物治疗。结果：10例感染性心内膜炎药物治愈2例。手术治疗8例，治愈5例，手术死亡3例。其中2例因感染导致瓣周漏致左心功能严重损害，1例因再交感染致主动脉瓣及升主动脉坏死。结论：感染性心内膜炎药物保守治疗效果不佳者应尽早手术治疗，可得到满意效果。对感染引起的瓣周漏致左心功能不全者应立即果断进行手术治疗。反之则会引起严重后果。     

Differential diagnosis using artificial neuronal networks

In order to rule out the effects of subjective factors and decrease the number of diagnostic errors, artificial neuron nets are proposed. By means of these nets the subjective and half-empirical heuristics are replaced with rational diagnostic information based on quantitative and logic analysis. The proposed method was used for deriving the decisive regularities ensuring the differential diagnosis between infective endocarditis and active rheumatic fever, infective endocarditis and systemic lupus erythematosus, and systemic lupus erythematosus and active rheumatic fever. Reliability of diagnostic tables representing the decisive regularities in the usual form is confirmed by clinical data.     

手术治疗感染性心内膜炎70例临床分析

目的:讨论感染性心内膜炎患者临床特征、手术指征和超声心动图特点。方法:对70例手术治疗的感染性心内膜炎患者临床资料进行回顾性分析。结果:术后早期死亡7例(10%),死于脑血管意外3例,死于多脏器功能衰竭3例,死于肾功能衰竭1例。结论:感染性心内膜炎最常见的手术指征是重度反流性心力衰竭。左心室收缩功能下降(左心室射血分数<50%)预示着较高的围术期病死率。     

感染性心内膜炎的临床变迁（附116例临床分析）

目的 探讨感染性心内膜炎(IE)的病因、致病微生物的变化、临床变迁及预后等因素，提高IE的诊治水平。方法 对1990年6月-2002年6月住院的116例IE患基础心脏病情况、主要临床表现、血培养、超声心动图检查、治疗结果及预后等进行分析。结果 IE基础心脏病中，先天性心脏病的比例(34．5％)有所升高，而风湿性心脏病的比例(25．9％)有所下降，无器质性心脏病的比例(19．O％)较既往国内外报道的发病率有明显的提高。血培养阳性率为41．4％，草绿色链球菌是IE的主要致病菌(29．2％)；近年来，发现条件致病菌假单胞菌属引起IE(本组4例)。超声心动图探测心内赘生物的比例为65．5％。人工瓣膜性IE发病率(17．2％)有所升高，死亡率为25．O％。本组死亡13例(11．2％)，本病预后严重。结论 IE基础心脏病和致病菌发生较明显变化，超声心动图对IE诊断及治疗有重要价值，本病预后严重，人工瓣膜性IE发病率及死亡率高，应尽早手术治疗。     

感染性心内膜炎的外科治疗

目的总结感染性心内膜炎（IE）的外科治疗经验。方法1994年4月至2007年6月，本院120例IE患者在接受内科抗感染治疗的同时，采取积极的外科手术治疗。结果围术期死亡1例（0．83％），远期IE复发死亡2例，其余患者经随访心功能均恢复至Ⅰ～Ⅱ级。结论外科手术治疗感染性心内膜炎是一种有效的治疗措施，降低了感染性心内膜炎的病死率。正确掌握手术时机，彻底清除感染病灶，恢复瓣膜功能以及围手术期应用有效抗生素是提高感染性心内膜炎治愈率的关键。     

The diagnostic ability of echocardiography for infective endocarditis and its associated complications

Echocardiography, transthoracic and transoesophageal, plays a key role in the diagnosis and prognosis assessment of patients with infective endocarditis. It constitutes a major Duke criterion and is pivotal in treatment guiding. Seven echocardiographic findings are major criteria in the diagnosis of infective endocarditis (IE) (vegetation, abscess, pseudoaneurysm, fistulae, new dehiscence of a prosthetic valve, perforation and valve aneurysm). Echocardiography must be performed as soon as endocarditis is suspected. Transoesophageal echocardiography should be done in most cases of left-sided endocarditis to better define the anatomic lesions and to rule out local complications. Transoesophageal echocardiography is not necessary in isolated right-sided native valve IE with good quality transthoracic examination and unequivocal echocardiographic findings. Echocardiography is a very useful tool to assess the prognosis of patients with IE at any time during the course of the disease. Echocardiographic predictors of poor outcome include presence of periannular complications, prosthetic dysfunction, low left ventricular ejection fraction, pulmonary hypertension and very large vegetations.     

Time interval between infective endocarditis first symptoms and diagnosis: relationship to infective endocarditis characteristics,microorganisms and prognosis

Objective: To analyze the characteristics and outcome of infective endocarditis (IE) according to the time interval between IE first symptoms and diagnosis.

Methods: Among the IE cases of a French population-based epidemiological survey, patients having early-diagnosed IE (diagnosis of IE within 1 month of first symptoms) were compared with those having late-diagnosed IE (diagnosis of IE more than 1 month after first symptoms).

Results: Among the 486 definite-IE, 124 (25%) had late-diagnosed IE whereas others had early-diagnosed IE. Early-diagnosed IE were independently associated with female gender (OR?=?1.8; 95% CI [1.0–3.0]), prosthetic valve (OR=?2.6; 95% CI [1.4–5.0]) and staphylococci as causative pathogen (OR?=?3.7; 95% CI [2.2–6.2]). Cardiac surgery theoretical indication rates were not different between early and late-diagnosed IE (56.3% vs 58.9%), whereas valve surgery performance was lower in early-diagnosed IE (41% vs 53%; p?=?.03). In-hospital mortality rates were higher in early-diagnosed IE than in late-diagnosed IE (25.1% vs 16.1%; p?Conclusions: The time interval between IE first symptoms and diagnosis is closely related to the IE clinical presentation, patient characteristics and causative microorganism. Better prognosis reported in late-diagnosed IE may be related to a higher rate of valvular surgery.

• KEY MESSAGES

• Infective endocarditis, which time interval between first symptoms and diagnosis was less than one month, were mainly due to Staphylococcus aureus in France.

• Staphylococcus aureus infective endocarditis were associated with septic shock, transient ischemic attack or stroke and higher mortality rates than infective endocarditis due to other bacteria or infective endocarditis, which time interval between first symptoms and diagnosis was more than one month.

• Infective endocarditis, which time interval between first symptoms and diagnosis was more than one month, were accounting for one quarter of all infective endocarditis in our study and were associated with vertebral osteomyelitis and a higher rate of cardiac surgery performed for hemodynamic indication than other infective endocarditis.

     

Endocarditis and myocarditis: a brief review

Endocarditis and myocarditis are conditions seen worldwide with considerable morbidity and mortality. Despite the improvements in diagnostic technologies, clinical diagnosis remains crucial as only prompt recognition will lead to appropriate investigations and timely intervention, which may be life saving. In this review, the authors provide a concise overview of endocarditis and myocarditis.