Pulmonic valve endocarditis as an underdiagnosed disease: role of transesophageal echocardiography.

Pulmonic valve endocarditis is a rare clinical entity. In spite of an increase in the frequency of right-sided endocarditis, primarily it is the tricuspid valve that is involved. Two-dimensional transthoracic echocardiography has improved our ability to diagnose infective endocarditis but has not identified many cases of pulmonic valve endocarditis. With the use of transesophageal echocardiography, three recent cases of pulmonic valve endocarditis were diagnosed by our laboratory. Each of these patients had clinical evidence of right-sided endocarditis, yet routine transthoracic echocardiograms failed to identify any pulmonic valve abnormalities. The true incidence of pulmonic valve endocarditis may be higher than previously reported, and the transesophageal echocardiogram is the preferred method for identifying and evaluating pulmonic valve endocarditis in adults.     

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.     

Diagnoses of right-sided empyema complicating tricuspid valve endocarditis during transesophageal echocardiography.

A 25-year-old man, who was a known intravenous drug user, underwent transesophageal echocardiography as part of investigation for suggested infective endocarditis. Tricuspid valve infective endocarditis was diagnosed. The simultaneous visualization of right-sided empyema, previously undiagnosed, by transesophageal echocardiography, led to operative treatment by thoracoscopy and right lung decortication.     

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。     

Nonbacterial thrombotic endocarditis demonstrated by repeat echocardiography

We report a case of nonbacterial thrombotic endocarditis (NBTE) in a patient with bladder cancer presenting with multiple cerebral infarctions. Initial transthoracic and transesophageal echocardiography did not show any abnormalities. However, repeat transthoracic and transesophageal echocardiography demonstrated a vegetation on the anterior leaflet of the mitral valve with mild mitral regurgitation and no evidence of leaflet destruction. Persistent high-grade fevers and leukocytosis were observed. The patient was suspected to have infective endocarditis. However, abdominal ultrasound and computed tomography scan revealed multiple metastatic masses, and serial blood cultures were negative. The patient was ultimately diagnosed with NBTE associated with multiple metastases of bladder cancer. This case suggests that even if echocardiography does not initially demonstrate any abnormalities in patients with embolism, it must be repeated at the recurrence of embolism, and that even if clinical signs of infection are documented, NBTE should be suspected in any cancer patient with thromboembolic events.     

Aneurysm of the anterior leaflet of the mitral valve secondary to aortic valve endocarditis.

Aneurysm of the anterior mitral leaflet is a rare complication of infective aortic valve endocarditis, the natural evolution of which is generally its rupture, with subsequent acute and severe mitral regurgitation. Its presence cannot be recognized with transthoracic echocardiography and even in surgery. We describe a 78-year-old man with aortic valve endocarditis, in whom transesophageal echocardiography was essential for the diagnosis of this complication, its therapeutic management, and the postoperative follow-up after simple valve repair. In addition, the most appropriate surgical approach is discussed.     

Swan-Ganz catheter-related pulmonary valve infective endocarditis: A case report

We report the case of a 29-year-old man with decompensated alcoholic cardiomyopathy who developed a Staphylococcal pulmonic valve infective endocarditis during hemodynamic monitoring, as a consequence of catheter-related bacteremia. As experimentally demonstrated, the damaging role of the pulmonary artery catheter on the endocardial surface plays a major role in the pathogenesis of related right-sided infective endocarditis. Occurrence of bacteremia in a catheterized patient should be considered as a high risk situation, and righ-heart infective endocarditis must be suspected whenever patient presents fever or bacteremia without obvious site of infection. Doppler echocardiography is the reference diagnosis procedure.     

经胸超声心动图在诊断感染性心内膜炎中的应用

目的 评价经胸超声心动图诊断感染性心内膜炎的价值。方法 回顾性分析114例感染性心内膜炎患者的经胸超声心动图特征及临床资料,观察心脏瓣膜形态结构、活动及对合功能,寻找赘生物,观察瓣周结构及有无基础心脏病变。结果 114例患者中,104例以发热为首发症状,69例有基础心脏病,5例有全身性疾病。血培养阳性35例。超声示累及二尖瓣46例、主动脉瓣48例、三尖瓣17例、肺动脉瓣1例、人工瓣膜9例,其中多瓣膜受累7例;存在严重并发症19例。59例接受手术患者中,56例检出赘生物,术前超声诊断正确,诊断正确率为94.92%（56/59）。结论 经胸超声心动图可准确诊断感染性心内膜炎。     

Infective endocarditis of the pulmonary valve following pulmonary artery catheterisation

The risk of infective endocarditis following pulmonary artery catheterisation in patients with sepsis remains unquantified. Although catheter-induced endocardial and valvular injury are well recognised, valve infection is rare. A case of mixed pulmonary valve endocarditis associated with the use of a pulmonary artery catheter (PAC) in a patient with multisystem failure following liver trauma is described. This illustrates that diagnosis of infective endocarditis in critically ill patients can be difficult because concurrent illness and therapy may mimic or mask the usual presenting signs. The value of transoesophageal echocardiography in this context is emphasised.     

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     

Echocardiographic detection of aortic valve ring abscesses

Valve ring abscess complication of infective endocarditis increases the expected morbidity and mortality rates of patients, but is seldom recognized by available noninvasive techniques. In our study, two-dimensional echocardiography successfully detected valve ring abscesses in eight patients with infective endocarditis affecting aortic valve prosthesis. Echocardiography showed the perivalvular abscess as an echo-free space in all patients. Prosthetic vegetations were seen in the only patient who had a biological prosthesis and excessive prosthetic rocking was observed in cases with severe aortic regurgitation. In two patients, the first echocardiographic examination showed an echo-free space without evident clinical signs of endocarditis or significant valve regurgitation. Severe aortic insufficiency and congestive heart failure followed the enlargement of the echo-free space. Valve replacement was required in all but one patient. The echocardiographic findings were confirmed at surgery. In one patient, the extension of the abscess to the interventricular septum was not detected by the echocardiography.     

Unusual cases of infective endocarditis.

We report 2 patients with unusual cases of infective endocarditis. The first patient had a large, mural vegetation on left ventricle that was diagnosed with transthoracic echocardiography; and the second patient had a large, mobile vegetation in the descending prosthetic aorta with an abscess cavity around the vessel, diagnosed by transesophageal echocardiography. This report confirms the usefulness of transthoracic and transesophageal echocardiography in the diagnosis and management of uncommon cases of endocarditis.     

THE ROLE OF ECHOCARDIOGRAPHY IN THE DIAGNOSIS AND MANAGEMENT OF INFECTIVE ENDOCARDITIS

The echocardiographic appearance in suspected endocarditis must always be interpreted in the context of the clinical findings. Thus although echocardiography may contribute to the early diagnosis of infective endocarditis, it should rarely be used as a screening test. It is highly sensitive for the detection of complications such as abscesses or valvular regurgitation and can estimate their severity. Although transthoracic imaging will allow a complete study in many cases, the transoesophageal approach is superior for the detection of abscesses and the assessment of prosthetic mitral valves. Patients with large vegetations, particularly on the mitral valve, are at increased risk of embolism but there is no convincing evidence to support prophylactic surgery in these cases.     

Tricuspid valve endocarditis: Cardiovascular imaging evaluation and management

Right-sided infective endocarditis is an increasingly recognized disease entity, with tricuspid valve being most frequently involved. Risk factors for tricuspid valve endocarditis (TVIE) include intravenous drug use, cardiac implantable electronic devices and indwelling catheters. Staphylococcus aureus is the predominant causative organism in TVIE. The diagnosis of infective endocarditis (IE) is based on clinical manifestations, blood cultures, and the presence of valvular vegetations detected by echocardiography. Complementary imaging is helpful when there is ongoing clinical suspicion for IE following initially negative echocardiography. Multislice computed tomography allows for assessment of extra-cardiac complications in TVIE, including pulmonary septic emboli. 18F-fluorodeoxyglucose positron emission tomography/computed tomography and radiolabelled white blood cell, single-photon emission computed tomography provide important clinical information concerning the presence of IE in right-sided prosthetic valves or cardiac implantable electronic devices. The aim of this review is to provide an update on TVIE, discussing the role of multimodality imaging in TVIE and the management of these patients.     

Osteoarticular infection complicating enterococcal endocarditis

Despite the common occurrence of musculoskeletal complaints in patients with infective endocarditis, infectious osteoarticular complications are diagnosed infrequently. Moreover, although enterococcal infection is the third most common cause of infective endocarditis, infectious osteoarticular complications are rare. We report a case of disk space infection in a patient with enterococcal endocarditis. Blood cultures and an L3-4 aspirate grew Enterococcus faecalis, and transthoracic echocardiography revealed a large vegetation on the posterior mitral valve leaflet. The osteoarticular infection resolved with antimicrobial treatment, but worsening heart failure necessitated valve replacement surgery. The patient had an uneventful recovery with no evidence of recurrence or complications. A review of the medical literature from 1966 through 1998 identified 13 additional cases, only 8 of which provided clinical and treatment data. We present the clinical and laboratory findings reported in these cases, along with data from our patient. This report highlights the rare occurrence of osteoarticular infection in the setting of enterococcal endocarditis and emphasizes early recognition and treatment.     

The role of echocardiography in the diagnosis and management of infective endocarditis.

The echocardiographic appearance in suspected endocarditis must always be interpreted in the context of the clinical findings. Thus although echocardiography may contribute to the early diagnosis of infective endocarditis, it should rarely be used as a screening test. It is highly sensitive for the detection of complications such as abscesses or valvular regurgitation and can estimate their severity. Although transthoracic imaging will allow a complete study in many cases, the transoesophageal approach is superior for the detection of abscesses and the assessment of prosthetic mitral valves. Patients with large vegetations, particularly on the mitral valve, are at increased risk of embolism but there is no convincing evidence to support prophylactic surgery in these cases.     

Embolization of a huge tricuspid valve bacterial vegetation.

A case of a woman who had tricuspid valve bacterial endocarditis is presented. Her course was complicated by persistent disseminated intravascular coagulation and acute renal failure, followed by pulmonary embolization of the vegetation. Transthoracic echocardiography showed almost complete obstruction of the right pulmonary artery. The case demonstrates the impressive size to which right-sided infective vegetations can progress and the relative paucity of symptoms and hemodynamic derangements with which they may be associated, even in the context of potentially life-threatening complications.     

Echocardiography in infective endocarditis.

BACKGROUND: Echocardiographic demonstration of valvular infection now ranks with positive blood cultures as one of the two major clinical criteria for diagnosis of infective endocarditis (IE), according to new, more accurate guidelines for diagnosis. Because early detection of IE and its complications is essential for determining whether to pursue medical therapy or to intervene surgically, transthoracic echocardiography (TTE) is an essential part of the initial examination of patients with suspected IE. METHODS: Using MEDLINE, we searched and reviewed all articles with the key words infective endocarditis and transesophageal echocardiography. RESULTS: With its superior imaging, transesophageal echocardiography (TEE) has proven to be more sensitive than TTE for the diagnosis of IE as well as in the detection of IE-associated complications. CONCLUSIONS: While superior in predicting which patients with IE have perivalvular abscess or prosthetic valve dysfunction and which are most susceptible to systemic embolism, TEE is more invasive and must be used selectively.     

Appropriate use of echocardiography in managing Staphylococcus aureus bacteremia

Staphylococcus aureus bacteremia (SAB) is increasing, both in the community and in healthcare settings. Accurate and timely diagnosis of underlying infective endocarditis (IE) is critical for optimal management of SAB cases as it has significant management and prognostic implications. Reported prevalence of IE in patients with SAB varies depending on the study population, and ranges from 10 to 30%. As clinical presentation of IE can be nonspecific, echocardiography is usually recommended in SAB cases to 'rule out' IE. Due to its poor sensitivity (<50%), especially for diagnosing prosthetic valve IE, transthoracic echocardiography is considered inadequate in this setting and clinicians have to rely on transesophageal echocardiography (TEE) to confirm or exclude endocarditis in SAB cases. Although some experts recommend TEE in all patients presenting with SAB, it is believed that the use of TEE could be guided by individual patient risk factors, mode of acquisition of SAB and clinical presentation. In this article, published data regarding the use of TEE in the SAB population are reviewed and a simplified algorithm to guide use of TEE in SAB cases is proposed.     

Transesophageal echocardiographic identification of an aortic root to right atrial fistula in a patient with acute streptococcal aortic valve bacterial endocarditis.

We describe the case of a patient with acute aortic valve endocarditis complicated by aortic insufficiency, perivalvular abscess, and aortic root to right atrial fistula caused by Streptococcus pneumoniae bacterial infective endocarditis. Although typically of low sensitivity for the diagnosis of myocardial abscess and similar complications of infective endocarditis, transthoracic echocardiogram successfully identified this relatively uncommon complication that was later confirmed by transesophageal echocardiography and at time of operation.