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Steven J. Lester, MD, FACC, FRCPC; Susan Wilansky, MD, FACC, FRCPC
Echocardiography is a most useful bedside tool to help in the diagnosis and management of infective endocarditis. (Crit Care Med
diagnosis and subsequent management of patients with infective 2007; 35[Suppl.]:S384–S391)
endocarditis. Transesophageal echocardiography provides comple- KEY WORDS: endocarditis; transesophageal echocardiography;
mentary and often incremental information necessary in making a transthoracic echocardiography; M-mode echocardiography; sur-
diagnosis, and in identifying associated intracardiac complications. gical complications
This chapter will focus on the role of echocardiography in the
A
n infection of the endocardium There are two fundamental predispos- prosthetic heart valve or new dysfunction
or lining layer of the heart is ing factors for the development of infec- in a prosthetic heart valve warrants an
called infective endocarditis. tive endocarditis: a susceptible cardiac or evaluation for endocarditis.
Although most commonly as- vascular substrate (endothelial injury) In the absence of a “definite” patho-
sociated with a process involving the and a microbiological source. Endothelial logic diagnosis made at the time of open-
valve leaflets, it also may affect the chor- injury is influenced by aberrant intracar- heart surgery or autopsy, the diagnosis of
dae, chamber walls, paraprosthetic tissue, diac flow, where either a high-velocity jet infective endocarditis primarily involves
implanted shunts, conduits, and fistulas. directly impacts the endothelial surface the integration of clinical, microbiologi-
This condition was first described by Sir or there is increased shear stress second- cal, and echocardiographic data. In 1994,
William Osler during his Gulstonian lec- ary flow across a narrowed orifice or from Dr. Durack and colleagues (6) from Duke
tures delivered at the Royal College of a high- to a low-pressure chamber. As a University proposed a schema (The Duke
Physicians in March of 1885 at a time consequence of the Venturi effect, micro- Criteria) with which to stratify patients
when it was considered universally fatal biological deposits are maximal at the with suspected endocarditis into one of
(1). In 1906, Dr. Libman (2) addressed low-pressure sink, immediately beyond three categories— definite, possible, and
the medical society of The Johns Hopkins an orifice, or at the site where the jet rejected— using old (nonechocardio-
Hospital on his experience with a new stream directly strikes the surface. Sur- graphic) and new (echocardiographic)
process of blood cultures: “The most in- gery, dental procedures, or instruments criteria. The American Heart Association
teresting condition connected with the becoming involved with mucosal surfaces scientific statement on infective endocar-
subject of bacteriemias is endocarditis. or contaminated tissues may provide the ditis supports minor modifications to the
The study of these cases by means of microbiological source that incites the Duke Criteria proposed by Li and col-
blood cultures makes very definite disease process of infective endocarditis. leagues (7, 8) (Table 1).
Leube’s view that the acute endocarditis It should be noted that 10% to 20% of
is secondary to infection.” The realization adults who develop endocarditis may Blood Cultures
that this condition is secondary to an have no pre-existing heart disease (3).
infectious process, the availability of di- A detailed account of the microbiology
agnostic blood-culture techniques, the Diagnosis of endocarditis is beyond the scope of this
discovery of antibiotics, the development review; however, it is noted that staphy-
of surgical interventions for valvular and The clinical diagnosis requires the lococci and streptococci account for the
perivalvular complications, and the ability physician to maintain an index of suspi- majority of the cases with notable trends
to characterize the anatomical and hemo- cion, because the symptoms often are toward a rising prevalence of staphylo-
dynamic manifestations of this disease with only constitutional and many of the Os- coccal skin flora caused by iatrogenic
echocardiography have significantly im- lerian manifestations (4) absent, except nosocomial infection, Staphylococcus
proved treatment of this disease. for subacute or chronic forms of the dis- aureus affecting intravenous drug users,
ease. The diagnosis should be considered and Streptococcus bovis in the elderly
in individuals with a fever and embolic often associated with an underlying gas-
phenomenon, a predisposing endocardial trointestinal neoplasm. Culture negative
From the Mayo Clinic Arizona, Scottsdale, AZ. lesion, or bacteremia. Fever may be min- infective endocarditis may be noted in up
For information regarding this article, E-mail: imal or absent in the elderly or those with to one-third of cases (9). This most com-
lester.steven@mayo.edu
Dr. Wilansky has not disclosed any potential con- congestive heart failure or chronic renal monly is a consequence of prior antibi-
flict of interest. failure; occasionally, fever also is minimal otic use, but an increasingly common
Copyright © 2007 by the Society of Critical Care or absent when associated with coagulase scenario is infection by fastidious organ-
Medicine and Lippincott Williams & Wilkins negative staphylococci (5). The mere isms with limited proliferation under
DOI: 10.1097/01.CCM.0000270275.89478.5F presence of a fever in an individual with a conventional culture conditions (10).
tation; however, large bulk vegetations creased pressure from an expanding space- 33, 36 –39). The tendency is for the infec-
may result in flow obstruction. Valve re- occupying lesion—may rupture, creating tion to extend into the weakest portion of
gurgitation may progressively worsen fistulous communications commonly from the paravalvular structure, and in the
with ineffective medical management of the aorta to left atrium or left ventricle to case of the aortic valve this is the mem-
the underlying infectious organism, or right atrium. In individuals with aortic valve branous septal area, which contains the
may present acutely as a result of leaflet endocarditis and associated aortic regurgi- conducting tissue and hence the associa-
perforation or destruction of the valvular tation, the “infected” regurgitant jet may tion with new conduction abnormalities
supporting structures. Echocardiography cause local spread of infection as it strikes (40).
is the tool that best allows us to identify subaortic structures. Such complications Although a number of proposed clini-
such complications. Careful evaluation is can include aneurysm or perforation of cal parameters associated with periannu-
required when one is questioning the di- the anterior mitral-valve leaflet, or if the lar extension are listed above, the pres-
agnosis of a prolapsing or flail-valve leaf- jet impinges the mitral-aortic intervalvu- ence of new atrioventricular block is
let segment to ensure the appropriate dif- lar fibrosa, an abscess or aneurysm may likely the most reliable (35). The finding
ferentiation from highly mobile and form in that location (29 –31)(Fig. 5). of atrioventricular block on the electrocar-
prolapsing vegetations, because each may Periannular complications are more diogram has a reasonably positive predic-
have similar visual tissue characteristics commonly encountered in prosthetic tive valve (88%); however, the sensitivity of
and motion patterns (Fig. 3). Objective (56 –100%) than native (10 – 40%) valve this finding to detect a periannular ab-
quantification of the extent of either ste- endocarditis, because in the latter the scess is low (45%) (35). The increased
nosis or obstruction is required, with a annulus, rather than the leaflet, is gener- patient mortality associated with perian-
detailed description of such methods be- ally the primary site of the infection (32– nular extension necessitates prompt eval-
yond the scope of this discussion. 35). There are a number clinical parameters uation of patients at risk. TEE is the mo-
Periannular Extension. Periannular felt to be associated with an increased risk for dality of choice in the evaluation for
extension of the infection into the adja- periannular extension, including those with a potential periannular extension. The re-
cent myocardium is a serious complica- fulminant presentation, persistent fever, ported sensitivity, specificity, and positive
tion associated with increased patient pericarditis, a history of intravenous drug and negative predictive values are 76% to
mortality (26 –28). Tissue necrosis and use, involvement of a prosthetic valve, 100%, 95%, 87%, and 89%, respectively
pyogenesis may result in the formation of and (importantly) electrical-conduction (12, 31, 41, 42). Spectral and color Dopp-
an abscess cavity (Fig. 4). The weakened, disturbance such as atrioventricular ler is used to characterize the flow pat-
necrotic myocardial tissue— under in- block or new bundle-branch block (32, terns of fistulous communications.