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Infective Endocarditis: A Comprehensive ApproachCME
DisclosuresWilliam C. Roberts, MD
Epidemiology and Pathology of Infective Endocarditis
William C. Roberts, MD (Baylor University Medical Center, Dallas, Texas, USA) beganthis session by illustrating various morphologic features of infective endocarditis. Thedisease has quite different presentations when it affects the aortic valve versus when itaffects the mitral valve, and when it affects a right-sided cardiac valve compared with aleft-sided cardiac valve.The most common site of infective endocarditis is the aortic valve. Infection of an aorticvalve usually involves all 3 cusps. The vegetation is located on the ventricular aspect of each cusp, and these contact each other during ventricular diastole. Therefore, it easy for the infection to spread from 1 cusp to another. Infection involving an aortic valve causesdysfunction by either perforation of 1 or more cusps or by indentations or tearing of 1 or more cusps.By contrast, infection on a mitral valve usually causes dysfunction by rupture of chordaetendinae. Perforation of a mitral cusp is relatively uncommon. About half of patients withmitral valve infective endocarditis have it because vegetations are displaced from theaortic valve and land on chordae tendinae or the anterior mitral leaflet, leading todestruction of the mitral valve. Valves that are the site of infection generally are valvesthat were previously normal or only mildly abnormal. Infection on a previously stenoticvalve is very uncommon, and infection on a valve that was previously calcified is quiteuncommon. The bicuspid aortic valve has a great propensity for infection. An aortic valvecusp that has prolapsed and is associated with ventricular septal defect is veryuncommon.The most common complication of infective endocarditis on the left side of the heart isring abscess, which can lead to a number of complications, such as ventricular septaldefect, pericarditis, complete heart block, or a high-degree bundle-branch block.Patients with infection on the right side of the heart present primarily with pulmonarycomplications, that is, septic emboli to the lung. Vegetations on the tricuspid valve should be removed primarily to prevent pulmonary emboli, which is usually the killer in patientswith right-sided infective endocarditis.
Clinical Diagnosis of Endocarditis
 
Joseph A. Kisslo, Jr, MD (Duke University Medical Center, Durham, North Carolina,USA) began by noting that the first set of criteria for diagnosis of active infectiveendocarditis were established by von Reyn and colleagues in 1982.
[1]
Based on the resultsof a study of 135 patients suspected of having active infective endocarditis, theseresearchers used 4 major classifications: definite, probable, possible, or rejected.
Definite
infective endocarditis was established by morphologic confirmation of theinfection by either surgery or autopsy.
Probable
infective endocarditis was established bythe presence of a precordial murmur and by a positive culture. But these criteria were problematic because few patients fell into the "definite" category. The categories were toorigid and not very practical from a clinical standpoint.Durack and colleagues
[2]
published new criteria for diagnosis of infective endocarditis in1994. They introduced echocardiography as part of the diagnostic criteria. None of theseauthors were actually echocardiographers, emphasizing that this was a very objective setof criteria. Major criteria for the Durack analysis include: positive cultures on 2 occasions before treatment, echocardiographic demonstration of an oscillating mass on a valve, and periannular abscess or evidence of dehiscence of a portion of a valve. Minor criteriainclude predisposition to infective endocarditis, fever, a vascular phenomenon, andimmunologic phenomena.The new criteria established by Durack and associates were far superior to those of vonReyn and colleagues. The new criteria refined treatment and improved care.
Transthoracic and Transesophageal Echocardiography: Which? When?
According to Randolph P. Martin, MD (Emory University School of Medicine, Atlanta,Georgia, USA), active infective endocarditis carries a very high risk of mortality andmorbidity and is very costly. Rapid diagnosis and rapid treatment yield the best outcome.The clinical presentation may vary markedly and may mimic many other conditions,including systemic immunologic diseases and certain cancers.The echocardiogram aids not only in diagnosis but in management. The transthoracicechocardiogram (TTE) has excellent specificity--approximately 98%. Thetransesophageal echocardiogram (TEE) has improved diagnosis over that with TTE because the TEE can pick up very small vegetations that would be overlooked by TTE. If a patient is suspected of having infective endocarditis, the first test should be a TEErather than a TTE. False-negative and false-positive findings occur with both of thesediagnostic tests, but they are less common with TEE. The TEE is particularly useful indiagnosing complications of infective endocarditis and, used properly, may be useful in preventing some complications.The highest incidence of systemic embolization with left-sided endocarditis occurs withvegetations on the mitral valve, although in Dr. Roberts' experience, emboli are morecommon with infections on the aortic valve. The risk of emboli increases as the size of the vegetations increases. Emboli are particularly common when the vegetations are >10
 
mm in maximal diameter. Periannular extension of the infection is associated with anextremely high mortality rate, and periannular abscesses are most common with infectionof an aortic valve. All patients with prosthetic infective endocarditis have periannular abscess. TEE is by far the best clinical means of diagnosing periannular abscess. New criteria have been established for diagnosis, management, and treatment of activeinfective endocarditis.
[3]
TEE rather than TTE should be used as the initial diagnostic tool when infectiveendocarditis is suspected; it improves diagnosis about 20% over TTE. This is particularlytrue for patients with prosthetic heart valves, patients with infection due to
Staphylococcus
or fungi, those with previous, healed infective endocarditis, and thosewho have prolonged symptoms before infective endocarditis is suspected. TEE maydetect vegetations when TTE may not.In summary, echocardiography is essential for diagnosis, and TEE is superior to TTE.
What is Optimal Medical Treatment?
Bijoy K. Khandheria, MD (Mayo Clinic, Rochester, Minnesota, USA) recalled that before the advent of penicillin in 1943, active infective endocarditis was 100% fatal, butmortality dropped by about 60% when penicillin became available. Nevertheless, 40% of the patients treated with penicillin still died. Two basic principles of antibiotic therapy for active infective endocarditis should be observed:
•
Use a bacteriocidal drug, not a bacteriostatic drug.
•
Repeat blood cultures until the blood is sterile. Blood cultures should be repeated48-72 hours after initiation of antibiotic therapy.Decisions about antibiotic therapy include the choice of drug, dose, duration of treatment,route of administration, and location where antibiotics are to be delivered (in-hospital or outpatient).In addition to administering antibiotic therapy, it is important to call the surgeon early;early surgical therapy for active infective endocarditis decreased the mortality by about50%.
What is Optimal Surgical Treatment?
James H. Oury, MD (International Heart Institute of Montana, Missoula, Montana, USA)discussed the following 3 issues:
•
When to operate:
The surgeon should be involved early in the treatment of  patients with active infective endocarditis.
•
Technique:
The decision must be made as to whether to repair a valve (excise thevegetation) or replace it. Adequate debridement of the infective material is
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