n infection of the endocardium or lining layer of the heart is calledinfective endocarditis.
Although most commonly as- sociated with a process involving the valve lea\ufb02ets, it also may affect the chor- dae, chamber walls, paraprosthetic tissue, implanted shunts, conduits, and \ufb01stulas. This condition was \ufb01rst described by Sir William Osler during his Gulstonian lec- tures delivered at the Royal College of Physicians in March of 1885 at a time when it was considered universally fatal (1). In 1906, Dr. Libman (2) addressed the medical society of The Johns Hopkins Hospital on his experience with a new process of blood cultures: \u201cThe most in- teresting condition connected with the subject of bacteriemias is endocarditis. The study of these cases by means of blood cultures makes very de\ufb01nite Leube\u2019s view that the acute endocarditis is secondary to infection.\u201d The realization that this condition is secondary to an infectious process, the availability of di- agnostic blood-culture techniques, the discovery of antibiotics, the development of surgical interventions for valvular and perivalvular complications, and the ability to characterize the anatomical and hemo- dynamic manifestations of this disease with echocardiography have signi\ufb01cantly im- proved treatment of this disease.
There are two fundamental predispos- ing factors for the development of infec- tive endocarditis: a susceptible cardiac or vascular substrate (endothelial injury) and a microbiological source. Endothelial injury is in\ufb02uenced by aberrant intracar- diac \ufb02ow, where either a high-velocity jet directly impacts the endothelial surface or there is increased shear stress second- ary \ufb02ow across a narrowed ori\ufb01ce or from a high- to a low-pressure chamber. As a consequence of the Venturi effect, micro- biological deposits are maximal at the low-pressure sink, immediately beyond an ori\ufb01ce, or at the site where the jet stream directly strikes the surface. Sur- gery, dental procedures, or instruments becoming involved with mucosal surfaces or contaminated tissues may provide the microbiological source that incites the disease process of infective endocarditis. It should be noted that 10% to 20% of adults who develop endocarditis may have no pre-existing heart disease (3).
The clinical diagnosis requires the physician to maintain an index of suspi- cion, because the symptoms often are only constitutional and many of the Os- lerian manifestations (4) absent, except for subacute or chronic forms of the dis- ease. The diagnosis should be considered in individuals with a fever and embolic phenomenon, a predisposing endocardial lesion, or bacteremia. Fever may be min- imal or absent in the elderly or those with congestive heart failure or chronic renal failure; occasionally, fever also is minimal or absent when associated with coagulase negative staphylococci (5). The mere presence of a fever in an individual with a
prosthetic heart valve or new dysfunction in a prosthetic heart valve warrants an evaluation for endocarditis.
In the absence of a \u201cde\ufb01nite\u201d patho- logic diagnosis made at the time of open- heart surgery or autopsy, the diagnosis of infective endocarditis primarily involves the integration of clinical, microbiologi- cal, and echocardiographic data. In 1994, Dr. Durack and colleagues (6) from Duke University proposed a schema (The Duke Criteria) with which to stratify patients with suspected endocarditis into one of three categories\u2014de\ufb01nite, possible, and rejected\u2014using old (nonechocardio- graphic) and new (echocardiographic) criteria. The American Heart Association scienti\ufb01c statement on infective endocar- ditis supports minor modi\ufb01cations to the Duke Criteria proposed by Li and col- leagues (7, 8) (Table 1).
A detailed account of the microbiology of endocarditis is beyond the scope of this review; however, it is noted that staphy- lococci and streptococci account for the majority of the cases with notable trends toward a rising prevalence of staphylo- coccal skin \ufb02ora caused by iatrogenic nosocomial infection,Staphylococcus
andStreptococcus bovis in the elderly often associated with an underlying gas- trointestinal neoplasm. Culture negative infective endocarditis may be noted in up to one-third of cases (9). This most com- monly is a consequence of prior antibi- otic use, but an increasingly common scenario is infection by fastidious organ- isms with limited proliferation under conventional culture conditions (10).
Echocardiography is a most useful bedside tool to help in the diagnosis and subsequent management of patients with infective endocarditis. Transesophageal echocardiography provides comple- mentary and often incremental information necessary in making a diagnosis, and in identifying associated intracardiac complications. This chapter will focus on the role of echocardiography in the
KEYWORDS: endocarditis; transesophageal echocardiography; transthoracic echocardiography; M-mode echocardiography; sur- gical complications
Three to \ufb01ve sets of blood cultures, each from a separate venipuncture, incu- bated in both aerobic and anaerobic at- mospheres, should be obtained over 24
hrs. If obtained before antibiotic admin- istration, the initial sets of blood cultures will generally be positive in individuals with bacterial endocarditis within a 48-hr to 72-hr period, obviating the need to continuously collect blood cultures be- yond this point (11). The \u201cmicrobiologi- cal adaptations\u201d to the Duke criteria sup- ported by the American Heart Association include the mere presence of a positive
blood culture forS. aureus, regardless of whether community-acquired or not; a single positive blood culture forCoxiella
blood cultures (antiphase 1 IgG antibody titre\ue0001:800) helpful in establishing the diagnosis when blood cultures may be negative (culture-negative endocarditis) (7). If the clinical suspicion for the diag- nosis of infective endocarditis remains, despite sterile blood cultures after 48 hrs to 72 hrs of incubation, one may request that the laboratory intensify efforts to re- cover fastidious organisms and initiate a serologic assessment for possible cause.
The ability to detect and characterize the hemodynamic and pathologic conse- quences of infective endocarditis has es- tablished the requirement of an echocar- diographic evaluation in individuals with suspected disease. M-mode echocardiog- raphy has relinquished its role to 2-di- mensional transthoracic (TTE) and trans- esophageal (TEE) imaging techniques as the ultrasound-imaging modalities most commonly employed in the evaluation of individuals with suspected endocarditis. Although limited, M-mode echocardiog- raphy still has a role in the evaluation of patients with suspected endocarditis. Its superior temporal resolution permits de- tection of vibratory oscillations of a veg- etation or associated disrupted cardiac structures uncharacterized by standard TTE- and TEE-imaging techniques. Dia- stolic vibrations of the aortic valve, or systolic vibrations noted during M-mode interrogation of the mitral valve, are not normal and represent a sensitive \ufb01nding for a vegetation, torn lea\ufb02et, or ruptured chordae.
Visualization of the endocardial lesion is the central objective of the echocardio- graphic examination in its role as a diag- nostic technique. Echocardiography clearly does not provide histologic diag- noses; however, there are image charac- teristics that support the designation of a valve mass to a vegetation. These include a) location that is in the path of a high- velocity jet or the upstream side of the valve when it regurgitates; b) motion that is chaotic and independent of the valve with \ufb01ne vibrations; c) shape that is
Clinical criteria
2 major criteria; or
1 major criterion and 3 minor criteria; or
5 minor criteria
Firm alternative diagnosis explaining evidence of IE; or
Resolution of IE syndrome with antibiotic therapy for\ue0014 days; or
No pathological evidence of IE at surgery or autopsy, with antibiotic therapy for\ue0014 days; or
Does not meet criteria for possible IE as above
Typical microorganisms consistent with IE from 2 separate blood cultures: Viridans
streptococci,Streptococcus bovis, HACEK group,Staphylococcus aureus; or community-
acquired enterococci in the absence of a primary focus; or
supporting structures, in the path of regurgitant jets, or on implanted material in the
absence of an alternative anatomic explanation; or abscess; or new partial dehiscence of
prosthetic valve; new valvular regurgitation (worsening or changing or preexisting murmur
not suf\ufb01cient)
Minor criteria
Predisposition, predisposing heart condition, or IDU
Fever, temperature\ue00038\u00b0C
Vascular phenomena, major arterial emboli, septic pulmonary infarcts, mycotic aneurysm,
amorphous; d) texture that is gray scale and re\ufb02ectance in relation to the myocar- dium with calci\ufb01cation; and e) associated abnormalities such as abscess, \ufb01stula, new valve regurgitation for prosthetic valves, dehiscence, perivalvular leaks, and (rarely) obstruction (Fig. 1). Likely rep- resenting a degenerative process, small \u201cstinglike\u201d mobile strands with narrow attachment often are noted on valves. Similar \ufb01nding are noted around the sew- ing ring of valve prostheses, which too may represent a degenerative process or on occasion may represent a suture end. Redundant chordae or a pronounced Chiari\u2019s network may too at times be mis- taken for a pathologic \ufb01nding. However, these masses, by virtue of their shape and high re\ufb02ectance, can generally be differ- entiated from pathologic vegetation.
a vegetation are in\ufb02uenced by technical factors, by the experience of the imager and image interpreter, and by the pre-test likelihood of either having or not having the disease. With that said, the literature generally reports a sensitivity of 60% to 65% for TTE and 85% to 95% for TEE. The speci\ufb01city for both imaging tech- niques is very good at 90% to 98% (12\u2013 17). Signi\ufb01cant innovations to TTE im- aging have occurred since many of the studies with which the test characteris- tics reported above were performed. In- novations such as harmonic imaging, faster scanning and higher line densities, the use of higher-frequency transducers, and higher-resolution monitors\u2014although having salutary effects on overall image quality\u2014 have not signi\ufb01cantly in\ufb02uenced the sensitivity of TTE in the diagnostic eval- uation for infective endocarditis (18). The superior sensitivity of TEE over TTE is
even more pronounced in the evaluation of individuals with valve prostheses. In the setting of prosthetic-valve endocardi- tis, the sensitivity of TTE is generally reported to be below 50% while that of TEE remains between 82% and 90% (15, 19, 20).
A negative TEE has a negative predic- tive value of over 90%, but does not elim- inate the possibility, requiring as always interpretation to be integrated with good clinical judgment (21, 22). A false-negative echocardiographic evaluation may result from vegetations that are smaller than the image resolution, previous emboliza- tion, or simply recognizing that there are \u201cblind spots\u201d with TEE and TTE. If the clinical suspicion for infective endocardi- tis remains following an initial negative TTE or TEE examination, serial echocar- diographic evaluations may provide in- cremental diagnostic value (23). In addi- tion, integration of TTE with TEE images may be necessary, because views ob- structed in one imaging modality may not be obstructed in the other.
Whether to begin the evaluation with a TTE or directly proceed to a TEE is an issue of considerable intellectual and eco- nomic debate. Greaves and colleagues (24) noted that in the absence of clinical criteria that are signi\ufb01cant independent predictors for endocarditis (vasculitic/ embolic phenomena, central venous ac- cess or pacing wire, recent injected drug use, a prosthetic valve or a positive blood culture) there was a zero probability that a TTE would show any evidence of infec- tive endocarditis. Bayer and colleagues (25) propose a pragmatic approach to the echocardiographic evaluation of patients with suspected infective endocarditis, which we also support (Fig. 2).
Individuals with a history of endocar- ditis are at increased risk for future in- fection. Following completion of therapy, a TTE examination to establish a new baseline for valvular and ventricular mor- phology and function is very important. In individuals with poor acoustic win- dows or in whom there is complex anat- omy, a TEE may be required to establish a new baseline.
tural and functional integrity may be de- stroyed by the proliferation of an infec- tious organism within its tissue. The loss of function primarily results in regurgi-
