(IE)

INFECTIVE ENDOCARDITIS

Infective Endocarditis
A microbial infection of the membrane lining the heart. Usually confined to the external lining of a heart valve. Causes: Bacterial organisms: manifests as a vegetation on the valve - Streptococcus viridans (30-40%) - Staphylococcus aureus (70% in IV drug users) Prosthetic heart valves Pre-existing valvular disease Complications: Embolization - Valvular insufficiency and/or structural changes such as flail, perforation, abcess - Heart failure due to severe regurgitation

IE
History: - Fever of unknown origin (FUO) 80-90% - + blood cultures before antibiotics - Heart failure symptoms (dyspnea, etc) - Underlying heart disease ( MVP w/MR) - Recent invasive procedure (dental or IV drug use) - Flu-like symptoms - Chest pain (common in IV drug users)

IE
Physical exam: - New murmur - Skin lesions - Embolic event - Splenomegaly - Pallor (anemia)

Auscultation: Systolic/diastolic/continuous murmur(s) Order of frequency on valves: MV, Ao, TV, PV Other sites for IE: Pacer wires Eustachian valve Coarctation of the Aorta Mural thrombus

Classic triad for clinical diagnosis of IE: (combination of physical exam, laboratory, echo findings) Fever Positive (+) blood cultures New murmur
Major criteria: Persistent bacteremia w/ typical organisms Echo evidence of endocardial involvement Minor criteria: Pre-existing valve disease IV drug use Pulmonary or systemic embolic events Fever (signs of systemic infection)

IE Treatment: Prevention (Endocarditis prophylaxis for high risk) Antimicrobial therapy (4-6 weeks) Anticoagulation therapy ( embolic event) Digitalis/Diuretics for heart failure Valve repair or replacement Note: Echo alone cannot diagnose IE. Must correlate with symptoms, history, cultures. The absence of a vegetation does not rule out IE. Vegetation > 1 cm may indicate > risk of embolic event

Goals of Echo in patient with IE:

Identify presence, location, size, and # of vegetations Assess functional abnormalities of the valve (Regurg) Identify unerlying anatomy of the valve and disease

Assess impact on LV size and systolic function as well as the

effect on other chambers

Identify complications (abcess, pericardial effusion)

Infective Endocarditis
An abnormal echogenic, irregular mass Attachment on the upstream side of the valve leaflet Pattern of motion that is dependent on, but more chaotic

than, normal valve motion

M-mode of Aorta: Vegetations during systole (arrow)

M-mode of Mitral Valve: Thick echo in diastole (arrow)

IE Echo findings: Echo dense mass on valve, prosthesis, or myocardium Valvular vegetations: seen on flow side of valve Valvular insufficiency Chamber enlargements Volume overloads M-mode can show thickened lines of closure Valvular abcess: may see communication (colorflow) Usually normal or hyperdynamic LV systolic function Must evaluate the presence and severity of valvular regurgitations

Blood flow side of valve

Aortic Valve vegetation

A3C: Mitral Valve vegetation

Characteristics of Aortic Valve IE: Echogenic mass attached to the ventricular side of the leaflet Independent motion and prolapse into the LVOT in diastole
Characteristics of Mitral Valve IE: Typically located on the atrial side of the valve leaflets Independent motion and prolapse into the LA in systole Both are more easily detected in PLA and PSA views If seen in Parasternal and apical views this decreases the likelihood of artifact

Characteristics of Tricuspid Valve IE: Most often in IV drug users Associated with large vegetations (Staph. Aureus) Better prognosis compared to left heart vegetations Large, mobile mass attached to atrial side of valve Prolapse into RA in systole Septic pulmonary emboli are frequent complications RVIT, A4C, Subcostal views diagnostic

Infective Endocarditis (TEE)

IE Transesophageal Echo (TEE): Test of choice for IE if: - small (< 5mm) vegetations - pre-diseased native valves - Prosthetic heart valves TEE is excellent in detecting complications such as: - abcess - MV leaflet perforation - Mitral/Aortic intervalvular aneurysm

More than one valve can be affected Multiple views and careful examination are required

Infection may occur from

Direct extension Hematogenous spread Seeding from
MV chords (AR) RV free wall (VSD)
(Left):Pulmonary valve and aortic valve vegetation in patient with staph aureus endocarditis
Courtesy of American Society of Echocardiography

regurgitant jet through infected valve

RVIT

A4C

A4C

PLA