015Endocarditis //

CONTENTS

140 Principles of

141 Native Valve Endocarditis

143 Complications of Native Valve Endocarditis

145 Right Heart Endocarditis

145 Prosthetic Valve Endocarditis

146 Pacemaker/Polymer-Associated Endocarditis

147 Non-Infective/Abacterial Endocarditis

148 Indications for Surgery

139

Alles_EchoFacts_140821_KD.indd 139 28.08.14 21:13 015 // ENDOCARDITIS

NOTES PRINCIPLES OF ENDOCARDITIS

The prevalence of Definition endocarditis associated with prothetic valves and Endovascular microbial infection of cardiovascular structures pacemaker leads is on the increase. Location • Valves • Large intrathoracic vessels • Ventricular and atrial • Prosthetic material • Polymere associated structures (lines) • Eustachian valve

TRICUSPID VALVE ENDOCARDITIS – apical four- chamber view RV optimized/2D

Endocarditis with a large vegetation attached to the native . Thickened leafl ets

TV vegetation

Vegetation is an infected Pathophysiology of Endocarditis mass attached to endocardial structures, such as valves or implanted intracardiac material. On 2D Embolism echo they frequently appear as oscillating structures of variable size Active infection and morphology.

Endocardial defect

Post endocarditis Non-significant Healing with Perforation endocardial lesion/ calcification/ fibrosis fibrosis/thickening

Principle of a ”super-infected” thrombus: The endothelial lesion initiates a repair process which involves thrombus formation. In the presence of bacteremia this thrombus may be super-infected. Further consequences include repair ad integrum, tissue destruction, embolism, and defect healing.

140

Alles_EchoFacts_140821_KD.indd 140 28.08.14 21:13 015 // ENDOCARDITIS

PRINCIPLES OF ENDOCARDITIS NOTES

Microbiology Staph. aureus infection predisposes to abscess Other 14% formation and complications of Culture negative 17% Staph. aureus 25% endocarditis!

Staph. epidermidis 13% Enterococcus 11% Strept. bovis 20%

MITRAL VALVE ENDOCARDITIS AMVL – PLAX zoomed/2D

A vegetation is attached to the tip of the anterior leaflet. Vegetation LA

Epidemiologic Facts on Endocarditis

• Large geographical variations in the • Increase in the elderly population incidence of endocarditis (3–10 • Sclerosis and aging also predispose to episodes/100.,000 person-years) endocarditis

NATIVE VALVE ENDOCARDITIS

Diagnosis, Symptoms and Findings Endocarditis may be manifested in many ways, many of which • Fever/night sweat may be atypical • Predisposing factors In the setting of infection, heart • Conjunctival petechiae murmur or atypical symptoms, • Janeway lesions Echo Culture think of endocarditis. Early • Roth spots diagnosis saves lives. • Splinter hemorrhages • Vegetations Blood culture and other signs of • Regurgitations Clinics infection (CRP, leukocytes, etc.) • Complications of endocarditis are equally important. A negative (abscessive destruction) blood culture does NOT rule out • Pericardial efusion endocarditis.

141

Alles_EchoFacts_140821_KD.indd 141 28.08.14 21:13 015 // ENDOCARDITIS

NOTES NATIVE VALVE ENDOCARDITIS

MITRAL VALVE ENDOCARDITIS – TEE surgical view/3D Vegetation

Large vegetation on the posterior leaflet prolapsing into the left atrium

Posterior leaflet

Anterior leaflet

Follow-up studies help to make Differential Diagnosis an accurate diagnosis (progression?). • Fibrosis/calcification • Tangential imaging of structures • Myxomatous degeneration (e.g. mitral • Old vegetations valve prolapse) • Tumors/thrombi • Lambl‘s excrescence/strands

Transesophageal Indication for Transthoracic Echo in echocardiography is not Suspected Endocarditis mandatory in isolated right-sided native valve endocarditis with good Clinical Suspicion of Endocarditis transthoracic quality.

TTE

Prosthetic Poor quality Positive Negative TTE valve, intercardiac Persistent clinical suspicion device

High Low

TEE TEE Stop

If the initial TEE is negative but endocarditis is still suspected, repeat TEE within 7–10 days

ESC guidelines 2009

142

Alles_EchoFacts_140821_KD.indd 142 28.08.14 21:13 015 // ENDOCARDITIS

NATIVE VALVE ENDOCARDITIS NOTES

What Else to Look For? ”Healing” usually leads to some degree of fibrosis or calcification • Involvment of other valves • Valve obstruction (large of the afected valve. • Regurgitations and resulting vegetations, rare) volume overload • Coronary embolization of • Myocardial function (right + left) vegetation leading to wall motion • Pericardial/pleural efusion abnormalites (rare)

COMPLICATIONS OF NATIVE VALVE ENDOCARDITIS

Complications Embolization is the primary manifestation of endocarditis in • Embolism • Pseudoaneurysm 28–47% of all patients. The risk • Valve destruction • Perforation of embolization depends on the • Regurgitation/ • Fistula size (>10 mm) and mobility of • Abscess • Mycotic aneurysm the vegetation. Exclude endocarditis in the setting of stroke and fever.

Types of Valve Destruction

MV perforation Fistula

Valve perforation is a hole in the cusp or leaflet which appears as an interruption in endocardial tissue continuity, best seen with color Doppler. In contrast, a fistula is a communication with neighbouring cavities that does not directly involve the valve (for instance, between the aorta and the left atrium).

Pseudoaneurysm – MV pseudo- intervalvular aneurysm fibrosa

Pulsatile perivalvular (echo-free) cavity communicating with the cardiovascular lumen.

143

Alles_EchoFacts_140821_KD.indd 143 28.08.14 21:13 015 // ENDOCARDITIS

NOTES COMPLICATIONS OF NATIVE VALVE ENDOCARDITIS

Types of Valve Destruction

AV ring abscess MV annular abscess

Perivalvular cavity filled with infectious material which has a non-homogeneous (echodense/echolucent) appearance

AV cusp MV flail leaflet rupture

Tear in the aortic cusp or chordal rupture, which usually leads to excentric regurgitation jets.

PSEUDOANEURYSM IN AV ENDOCARDITIS – TEE long-axis view/2D Pseudoaneurysm A pulsating cavity surounds the (pseudoaneurysm). Numerous vegetations are pre- AV sent at the aortic cusps. Vegetation

Communication to the left ventricle

144

Alles_EchoFacts_140821_KD.indd 144 28.08.14 21:13 015 // ENDOCARDITIS

RIGHT HEART ENDOCARDITIS NOTES

Causes of TV Endocarditis Tricuspid valve endocardits is very likely in patients with • Intravenous drug abuse • Indwelling catheters pulmonic abscess + drug abuse • Immunocompromised • Pacemaker + new heart murmur.

Tricuspid Valve Endocarditis – Facts Use atypical views to image • The most common organisms are • High recurrence rates. tricuspid valve endocarditis Staphylococcus aureus (60–80%) • Endocarditis frequently causes a flail and also look for pleural and Pseudomonas. tricuspid valve leaflet.. efusion (secondary to • Pulmonary hypertension, pulmonary • Tricuspid valve endocarditis may pulmonary infection). embolism or tricuspid regurgitation also occur in patients without may result in right heart failure. predisposing factors. • The prognosis is relatively good (10% inhospital mortality), but is poor in fungal infection.

Complications Tricuspid valve vegetations may become very large. • Valve destruction • Septic pulmonary embolism • Involvement of neighbouring cardiac • Lung abscess structures

PROSTHETIC VALVE ENDOCARDITIS

Risk Factors

• Heart failure • Valve degeneration • Wound complications • Prior history of endocarditis • Direct contamination during cardiac • Prosthesis thrombi (super-infection) surgery

Differential Diagnosis Prosthetic valve endocarditis is difcult to detect. • Artefacts • Strands Transesophageal echo is • Subvalvular residuals • Thrombus recommended in case of • Surgical materials • Hematoma suspicion. Find out which operation was Compare your findings with previous studies. performed, talk to the surgeon. Surgical material such as suture material or patches may mimic endocarditis.

145

Alles_EchoFacts_140821_KD.indd 145 28.08.14 21:13 015 // ENDOCARDITIS

NOTES PROSTHETIC VALVE ENDOCARDITIS

Prosthetic valve endocarditis Complications is a life-threatening condition and is associated • Periannular abscess • Valve dehiscence with a poor prognosis. • Pseudoaneurysms • Valve obstruction • Paravalvular leaks • Fistula

PERIANNULAR PROSTHETIC VALVE ABSCESS – TEE short- axis/2D

The echodense area surounding AV the prosthesis corresponds to a vegetation periannular abscess. Additionally, a large vegetation is seen on the Abscess rim of the cusps.

PACEMAKER/POLYMER-ASSOCIATED ENDOCARDITIS

Pacemaker lead infection is Predisposing Factors difcult to diagnose. A negative study does not rule out • Pouch/Pocket infection • Diabetes endocarditis. Combine • Impaired immunity • The surgeon‘s experience transthoracic and • Systemic infection • Advanced age transesophageal echo to • Temporary pacing before implantation visualize as many portions of the leads as possible.

Clinical Presentation

• Fever, subfebrile (recurrent) • Septic shock (acute) • Pulmonary embolism • Poor general condition • Local complications

Lead infection usually Typical Sites of Infection occurs at sites where the leads are in contact • Vena cava superior • Tricuspid annulus with the endothelium. • Right atrium • Tricuspid valve

146

Alles_EchoFacts_140821_KD.indd 146 28.08.14 21:13 015 // ENDOCARDITIS

PACEMAKER/POLYMER-ASSOCIATED ENDOCARDITIS NOTES

CENTRAL LINE ENDOCARDITIS Left atrium – apical four-chamber view/2D &TEE bicaval view/2D

Central line with its tip in the Vegetation right atrium. Mobile vegeta- Inf. Sup, vena cava tion attached to the catheter vena cava Mobile (thickened tip) on transthoracic structure echo (left) and the adjacent wall (right) seen in TEE. Catheter

Thickened catheter

NON-INFECTIVE/ABACTERIAL ENDOCARDITIS

Types • Libman-Sacks endocarditis • Marantic endocarditis • Antiphospholipid syndrome • Hypercoagulable state

Echo Characteristics

• Valve thickening • Small vegetations • Mild or moderate regurgitation • Pericardial efusion

Cardiac Manifestations of Libman-Sacks Endocarditis

• Valve thickening and vegetations • Left + right ventricular dysfunction • Mural thrombus • Pericardial efusion • Spontaneous contrast

LIBMAN-SACKS ENDOCARDITIS – Thickened apical three-chamber view/2D valve Patient with and antiphos- pholipid syndrome. Several small vegetations are seen on the mitral valve.

Vegetations

147

Alles_EchoFacts_140821_KD.indd 147 28.08.14 21:13 015 // ENDOCARDITIS

NOTES INDICATIONS FOR SURGERY

ESC Guidelines 2009

Recommendations for Surgery in (IE)

Heart Failure Timing Class Level

Aortic or mitral IE with severe acute regurgitation or valve obstruction, causing refractory pulmonary Emergency I B edema or cardiogenic shock

Aortic or mitral IE with fistula into a cardiac chamber or causing refractory pulmonary edema or shock Emergency I B

Aortic or mitral IE with severe acute regurgitation or valve obstruction and persistent heart failure or echocardiographic signs of poor hemodynamic tolerance (early mitral closure or Urgent I B pulmonary hypertension)

Aortic or mitral IE with severe regurgitation and no HF Elective IIa B

Uncontrolled Infection

Locally uncontrolled infection (abscess, false aneurysm, fistula, enlarging vegetation) Urgent I B

Persistent fever and positive blood cultures > 7 – 10 days Urgent I B

Infection caused by fungi or multiresistant Urgent I B organisms elective

Prevention of Embolism

Aortic or mitral IE with large vegetations and one or more embolic Urgent I B episodes despite appropriate antibiotic therapy

Aortic or mitral IE with large vegetations (>10 mm) and other predictors of complicated Urgent I B course of disease (heart failure, persistent infection, abscess)

Isolated very large vegetations (>15 mm) Urgent IIb B

148

Alles_EchoFacts_140821_KD.indd 148 28.08.14 21:13