015Endocarditis // CONTENTS 140 Principles of Endocarditis 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 endocardium • 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 tricuspid valve. 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 mitral valve 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/heart failure • 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 aortic valve (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