Echocardiographic assessment of vegetations in patients with infective endocarditis: prognostic implications

Today, echocardiography is the most important technique next to clinical findings and blood cultures in the diagnosis of infective endocarditis. The sensitivity of echocardiography, particularly the transesophageal approach, for detection of vegetations and endocarditis related valvular destructions is high. In addition, echocardiographic findings may have some prognostic implications. The size and mobility of vegetations stratifies endocarditis patients into a high risk group for arterial embolism. In particular, mobile vegetations attached to the mitral valve with a maximal diameter > 10 mm may be prone to embolic events. Furthermore, increase in size of vegetations during antimicrobial treatment may identify patients with no, or at least a prolonged, healing process. Also, a lack of increase in the echo density of vegetations under adequate antibiotic treatment may indicate a poor healing process and may necessitate more aggressive management. The demonstration of paravalvular abscesses by echocardiography, particularly by transesophageal echocardiography, identifies a subgroup of patients who will need urgent cardiac surgery before widespread tissue destruction has occurred.     

经食管三维超声心动图在主动脉瓣位感染性心内膜炎中的应用

目的 探讨经食管三维超声心动图（three-dimensional transesophageal echocardiography,3D-TEE）在诊断感染性心内膜炎（infective endocarditis,IE）主动脉瓣病变中的价值.方法 对49例通过经胸超声心动图（transthoracic echocardiography,TTE）与3D-TEE诊断IE主动脉瓣病变患者的超声诊断特点进行分析,以心脏外科术中所见为“金标准”,将超声特点（赘生物、瓣叶穿孔、瓣周脓肿）与手术结果进行对照.结果 3D-TEE对赘生物、瓣叶穿孔、瓣周脓肿诊出的敏感性及特异性均高于TTE,差异有统计学意义（P＜0.05）.对于检测长度＜（4.5±0.7）mm的赘生物,3D-TEE较TTE更加敏感,差异有统计学意义（P＜0.05）.对于检测瓣周脓肿,3D-TEE较TTE更加敏感,差异有统计学意义（P＜0.05）,且容易发现瓣周脓肿早期组织水肿的情况.结论 与TTE相比较,3D-TEE能更准确检测IE主动脉瓣病变,有效评价此类患者瓣周脓肿情况,具有重要的临床应用价值.     

Perforated giant mycotic aneurysm of mitral valve in a drug‐addicted young man: Rare complication of infective endocarditis

Infective endocarditis (IE) affects patients at high clinical risk and may present as an acute and rapidly progressive, subacute or chronic infection. Transthoracic and transesophageal echocardiography represent the key diagnostic method in IE diagnosis. In particular, three‐dimensional transesophageal echocardiography represents the imaging technique that allows to establish with adequate accuracy dimensions, shape, and localization of endocarditis vegetations. In our case, we show a huge vermiform mycotic aneurysm in an immunodeficient young drug‐addicted man with severe mitral valve regurgitation and the additive value of three‐dimensional transesophageal echocardiography in this specific clinical setting.     

Ruptured mitral valve aneurysm: A devastating complication of aortic valve endocarditis

Mitral valve aneurysm is a rare clinical entity that is mostly resulted from infective endocarditis, in particular, aortic valve endocarditis. Once mitral valve aneurysm ruptures and severe mitral regurgitation and hemodynamic instability develop, prompt surgery should be considered. Here we report a patient with ruptured mitral valve aneurysm associated with native aortic valve endocarditis that was improved after a successful mitral and aortic valve replacement surgery associated with antibiotic therapy for 6 weeks.     

经食管三维超声心动图在二尖瓣位感染性心内膜炎中的应用

目的评价经食管三维超声心动图（three-dimensional transesophageal echocardiography,3D-TEE）在二尖瓣位感染性心内膜炎（infective endocarditis,IE）中的应用价值。方法选择2008年6月至2012年5月期间,在广东省人民医院行超声心动图检查并结合临床诊断,最终经手术病理确诊为二尖瓣位IE患者20例为研究对象。所有患者术前均行经胸超声心动图（transthoracic echocardiography,TTE）及3D-TEE检查。以病理为金标准,比较TTE及3D-TEE对诊断心内膜受累各种表现形式的敏感性和特异性。结果手术病理证实二尖瓣位赘生物20例,合并瓣膜穿孔11例,瓣周脓肿3例,瓣膜瘤2例,人工瓣撕脱3例。TTE及3D-TEE诊断赘生物的敏感性为80%vs.90%,特异性为57%vs.86%;诊断瓣膜穿孔的敏感性为72%vs.91%,特异性为78%vs.89%;诊断瓣周脓肿的敏感性为33%vs.66%,特异性为82%vs.94%;诊断瓣膜瘤的敏感性为50%vs.100%,特异性为94%vs.94%;诊断人工瓣撕脱的敏感性及特异性均为100%。3D-TEE对赘生物的检出率均高于TTE,差异有统计学意义（P〈0.05）。结论 3D-TEE对诊断IE各种表现形式均有较高的敏感性和特异性,能准确显示赘生物位置、形态、大小及其与周围心脏结构的空间关系,对临床治疗方案的选择及预后评估有重要作用。     

Clinical relevance of vegetation localization by transoesophageal echocardiography in infective endocarditis.

Infective endocarditis is associated with significant morbidity and mortality, with valvular destruction and congestive heart failure being more common in patients with echocardiographically discernible vegetations. The transoesophageal approach affords consistently high quality images with excellent structural resolution. Two-hundred and eighty-one patients with clinically suspected infective endocarditis were studied, to evaluate the prognostic value of ascertaining the site of vegetations. Among them were 118 patients with vegetations attached to the aortic or mitral valve. These patients were followed for a mean period of 14 months. Mitral valve vegetations were associated with a significantly higher incidence of embolic events than vegetations on aortic valves (25% vs 9.7%). The incidence of abscess formation was higher in aortic than in mitral valve endocarditis (6% vs 0%), as were the need for surgical intervention (11% vs 5.5%) and mortality (1.6% vs 0%) respectively). Bivalvular endocarditis was associated with an increased rate of complications: embolism (50%), abscess formation (15%), surgery (35%) and mortality (10%). By multivariate analysis, echocardiographically accessible risk factors for subsequent embolism were a vegetation size of more than 10 mm and mitral valve involvement. Risk factors associated with in-hospital fatality were embolism, a vegetation size of more than 10 mm, and Staphylococcus aureus infection. Our data suggest that the site influences both the rate and the type of complications. Precise echocardiographic visualization of vegetations helps to stratify patients into a high-risk sub-group, perhaps warranting early prophylactic surgical intervention. Transoesophageal echocardiography may play an important role in assessing the clinical outcome for these patients.     

Echocardiographic study of patients with congenital heart disease and infective endocarditis

BACKGROUND: Infective endocarditis (IE) occurs with significant frequency in patients with congenital heart disease. The complications leading to increased morbidity and mortality may be detected by echocardiographic examination. This study was undertaken in order to identify echocardiographic findings that influence the outcome of patients with congenital heart disease and IE. METHODS: Twenty-five patients with an average age of 28 years were selected and divided into two groups according to evolution. Group I included patients who survived the infectious process, while Group II included patients who died during hospitalization or after release. RESULTS: Aortic valve disease was the most frequent anomaly. The clinical finding of most relevance for evolution during hospitalization was heart failure. Acute kidney failure and multiple organ failure from sepsis were the most common complications in patients who died. Echocardiograms established the diagnosis in all cases. Transesophageal studies revealed all periaortic abscesses. CONCLUSIONS: Echocardiography makes it possible to identify and evaluate complications associated with elevated morbidity and mortality in patients with congenital heart disease and IE.     

The prospective role of transesophageal echocardiography in the diagnosis and management of patients with suspected infective endocarditis

STUDY OBJECTIVES: Transesophageal echocardiography (TEE) has a high sensitivity for the diagnosis of infective endocarditis (IE), but the prospective role of TEE when added to a careful clinical examination has not been well-studied. DESIGN: We compared the results of TEE to a clinical evaluation by an infectious disease specialist in 43 consecutive patients in whom TEE was ordered to rule out IE. Prior to TEE, the patients were classified on clinical grounds as to their likelihood of IE using a modification of the von Reyn criteria. Changes in management occurring as a result of TEE also were evaluated. MEASUREMENTS AND RESULTS: TEE was positive in 11 patients, negative in 29, and indeterminate in 3. TEE was positive in 6 (46%) of 13 high probability patients, 2 (67%) of medium probability patients, and 3 (11%) of 27 low probability patients. A change in management based on TEE occurred in 4 (31%) patients with high probability, in no patients with medium probability, and in 1 (4%) patient with low probability. CONCLUSIONS: TEE confirms IE in patients with high probability of IE and often leads to a management change. However, TEE is unlikely to establish the diagnosis or change management in patients with low probability.     

Antibiotic Prophylaxis for Endocarditis Prevention During Transesophageal Echocardiography: Controversy, Consideration, and What Really Happens

A survey was conducted in order to gain a better understanding of actual practice policies followed by academically affiliated institutions regarding the use of prophylactic antibiotics during transesophageal echocardiography. Results revealed that 10 of the 20 centers routinely used intravenous antibiotic prophylaxis for high risk transesophageal echocardiography. However, 5 of the 20 centers did not use any prophylactic antibiotics routinely, and the remaining 5 centers used primarily oral prophylactic regimens. In addition, the type of patient that was considered high risk for which antibiotic prophylaxis was used differed among institutions. Practice guidelines in 4 of the 20 institutions have changed in the last 5 years. These findings demonstrate a wide variation in the actual practice policies of different institutions, probably reflecting, in part, the lack of convincing evidence that prophylactic antibiotics benefit this subgroup of patients.     

Mobilization of a Bacterial Vegetation Visualized During Transesophageal Echocardiography

In this report, we describe visualization during transesophageal echocardiography of an embolus leaving the heart from the mitral valve of a patient with infective endocarditis.     

Perforated aneurysms of left side valves during active infective endocarditis complicating hypertrophic obstructive cardiomyopathy.

The most frequent site of vegetative lesion in patients with hypertrophic cardiomyopathy is anterior mitral leaflet, due to chronic endocardial trauma arising from systolic anterior motion. We describe three cases of serious infective endocarditis complicated lesions (vegetation, aneurysm and perforation) on aortic and mitral valves, in patients with obstructive hypertrophic cardiomyopathy. In particular, we observed how severe valvular damage and dysfunction, combined with particular hemodynamic conditions, are followed by adverse clinical outcome. We performed transthoracic echocardiogram and transoesophageal echocardiography studies to define morphologic and hemodynamic features of infection, deciding the proper therapy and we planned the echocardiographic follow-up.     

Surgical treatment of active infective endocarditis: A single center experience

Objective

This study was undertaken to examine the outcomes of surgery for active infective endocarditis.

Methods

Fifty consecutive patients underwent surgery for active infective endocarditis in a tertiary care center between January 2000 and June 2003. Modified Duke Criteria was used to include the patients in the study.

Results

Mean age of the patients was 55.72 years (range 18-89 years). Underlying heart disease was the most common cause of acute infection, accounting for 30 % of all the cases. 16 % patients had a recent dental procedure and 10 % had a recent surgical procedure. The most common infective organism was staphylococcus aureus (24%), followed by streptococcus viridians (20%). The most common indications for surgery were congestive heart failure (CHF) (52%), embolic phenomenon (18%) and septic shock (10%). Most common postoperative complication was respiratory failure (30%) followed by renal failure (24%) pacemaker implantation 22%; stroke 18%, bleeding 16% and GI bleeding 2 %. Seven out of 50 patients died during hospital course that accounts for 14% of the motility rate.

Conclusions

Surgery for endocarditis continues to be challenging and associated with high operative mortality and morbidity. Age, shock, prosthetic valve endocarditis, impaired ventricular function, and recurrent infections adversely affect long-term survival.     

Pulmonary valve vegetations and flail leaflet detected by cross-sectional echocardiography in infective endocarditis: A case report

A case report is presented of a patient with subacute bacterialendocarditis affecting the pulmonary valve. There was no pasthistory of valvular heart disease or narcotic addiction andno other valve was involved. Serial echocardiograms demonstratedthe vegetations, but only cross-sectional echocardiography showedthe flail movement of the leaflet and the size and shape ofthe vegetations.