Chapter 7 - Infective endocarditis

https://doi.org/10.1016/B978-0-7020-4086-3.00007-2Get rights and content

Abstract

Infective endocarditis is a serious disease of the endocardium of the heart and cardiac valves, caused by a variety of infectious agents, ranging from streptococci to rickettsia. The proportion of cases associated with rheumatic valvulopathy and dental surgery has decreased in recent years, while endocarditis associated with intravenous drug abuse, prosthetic valves, degenerative valve disease, implanted cardiac devices, and iatrogenic or nosocomial infections has emerged. Endocarditis causes constitutional, cardiac and multiorgan symptoms and signs. The central nervous system can be affected in the form of meningitis, cerebritis, encephalopathy, seizures, brain abscess, ischemic embolic stroke, mycotic aneurysm, and subarachnoid or intracerebral hemorrhage. Stroke in endocarditis is an ominous prognostic sign. Treatment of endocarditis includes prolonged appropriate antimicrobial therapy and in selected cases, cardiac surgery. In ischemic stroke associated with infective endocarditis there is no indication to start antithrombotic drugs. In previously anticoagulated patients with an ischemic stroke, oral anticoagulants should be replaced by unfractionated heparin, while in intracranial hemorrhage, all anticoagulation should be interrupted. The majority of unruptured mycotic aneurysms can be treated by antibiotics, but for ruptured aneurysms, endovascular or neurosurgical therapy is indicated.

Section snippets

Definition

Infective endocarditis is a disease of the inner lining of the heart and cardiac valves, the endocardium, caused by a variety of infectious agents, ranging from streptococci to antibiotic-resistant bacteria, including fungi and rickettsia. Endocarditis causes constitutional, cardiac, and multiorgan symptoms and signs. The central nervous system can be affected in the form of meningitis, cerebritis, encephalopathy, seizures, brain abscess, ischemic embolic stroke, mycotic aneurysm, and

Classification

Infective endocarditis is traditionally divided into acute and subacute-chronic types, according to the temporal profile of onset. Classically, acute endocarditis usually occurs in previously normal valves and is associated with more aggressive agents and nosocomial infections, while the subacute-chronic form occurs in abnormal valves and is due to more common and “benign” bacteria.

Infective endocarditis constitutes a group of clinical situations, whose cause and location can vary. The Task

Historical aspects

Although several physicians had described valvular vegetations, and a few had studied endocarditis, including Laennec, Bouillaud, and Kirkes (Levy, 1985), the three Gulstonian Lectures on “malignant endocarditis” delivered by William Osler to the Royal College of Physicians in 1885, and published in the same year in the British Medical Journal, are considered the hallmark of modern medical thought in infective endocarditis (Osler, 1885). Mostly based on personal observations, Osler described

Epidemiology

Fortunately, infective endocarditis is not very frequent. The estimated incidence is 1.7–6.2/100 000/year (Mylonakis and Calderwood, 2001). A survey in France detected 30 cases per million inhabitants in 1 year (Hoen et al., 2002). The incidence has been stable for several decades. The disease is more common in men (2:1) and in the middle aged, although in recent times an increasing number of the elderly have been affected, due to increased survival and more aggressive diagnostic and therapeutic

Pathophysiology

As a rule, the valve endothelium and the endocardium are resistant to colonization and infection by circulating bacteria. In the absence of valve lesion, it is necessary to have either mechanical disruption of the endothelium or endothelial inflammation in order for valves to become colonized and infected (Que et al., 2005, Beynon et al., 2006, Prendergast, 2006, Habib et al., 2009).

Following mechanical disruption of endothelium, there is an exposure of the underlying extracellular matrix

Systemic, cardiac and multiorgan manifestations

Systemic manifestations of infective endocarditis include fever > 38°C (96% of the patients) (Murdoch et al., 2009), often associated with chills, poor appetite, and weight loss. Fever can be absent in patients with previous use of antibiotics and in endocarditis due to less virulent agents. A new regurgitant heart murmur can be found in half (48%) of the subjects and worsening of old murmur in 20%. Other classic clinical manifestations include active vasculitic phenomena such as splinter

Diagnosis

The diagnosis of infective endocarditis requires a high suspicion rate and pattern recognition in an appropriate clinical context. It also requires the judicious integration of clinical symptoms and signs, including those of central nervous system (CNS) involvement, with the results of ancillary procedures, namely laboratory, echocardiography and neuroimaging studies.

Prognosis

In-hospital mortality of patients with infective endocarditis ranges between 10% and 25% (Mansur et al., 1996, Netzer et al., 2002, Wallace et al., 2002, Hasbun et al., 2003, Chu et al., 2004, Delahaye et al., 2007, San Roman et al., 2007, Thuny et al., 2005, Murdoch et al., 2009). Acute prognosis is influenced by: (1) patient characteristics: older age, prosthetic valve, insulin-dependent diabetes, comorbidities; (2) cardiac complications: heart failure, periannular complications; (3)

Prevention

Until recently, there was consensus that infective endocarditis was preventable by using antibiotics in patients with cardiac diseases at risk of endocarditis during procedures associated with transient bacteraemia, such as dental, gastrointestinal, urogenital, and obstetrics procedures. This dominant view has been challenged by the lack of randomized controlled trials demonstrating the efficacy of antibiotic treatment (Oliver et al., 2008) and by the observation that comparable transient

Treatment

The treatment of endocarditis includes general measures, antimicrobial therapy and treatment of complications, namely systemic, cardiac, and neurologic. The essential aspect of the treatment of infective endocarditis is the eradication of the systemic and cardiac infection by the application of appropriate antimicrobial therapy and, if necessary, by cardiac surgery, which removes infected tissue and material, and drains abscesses.

Conclusions

Despite important improvements in the diagnostic technologies for heart and brain imaging, infective endocarditis remains a formidable diagnostic and therapeutic challenge. Its contemporary management requires the cooperation of cardiologists, cardiac surgeons, neurologists, neurosurgeons, neuroradiologists, intensivists, and specialists in infectious diseases. Most of the current recommendation and guidelines are based on low-quality evidence. The lack of robust information in such a serious

References (119)

  • S. Kiyan et al.

    A rare diagnosis in ED: cerebral pyogenic ventriculitis due to infective endocarditis

    Am J Emerg Med

    (2007)
  • P. Moreillon et al.

    Infective endocarditis

    Lancet

    (2004)
  • R.A. Nishimura et al.

    AAC/AHA 2008 guideline update on valvular heart disease: focused update on infective endocarditis: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons

    J Am Coll Cardiol

    (2008)
  • P. Parize et al.

    Les actualités dans l’endocardite infectieuse

    Rev Med Interne

    (2011)
  • J. Pepin et al.

    Chronic antiplatelet therapy and mortality among patients with infective endocarditis

    Clin Microbiol Infect

    (2009)
  • V. Pergola et al.

    Comparison of clinical an echocardiographic characteristics of Streptococcuc bovis endocarditis with that caused by other pathogens

    Am J Cardiol

    (2001)
  • P.J. Peters et al.

    A dangerous dilemma: management of infectious intracranial aneurysms complicating endocarditis

    Lancet Infect Dis

    (2006)
  • S. Rohmann et al.

    Prediction of rapid versus prolonged healing of infective endocarditis by monitoring vegetation size

    J Am Soc Echocardiogr

    (1991)
  • D.N. Salem et al.

    Valvular and structural heart disease. American College of Chest Physicians Evidence-Based Clinical Practice Guidelines, 8th edn

    Chest

    (2008)
  • A.J. Sanfilippo et al.

    Echocardiographic assessment of patients with infective endocarditis: prediction of risk of complications

    J Am Coll Cardiol

    (1991)
  • E. Shang et al.

    Mitral valve infective endocarditis: benefit of early operation and aggressive use of repair

    Ann Thorac Surg

    (2009)
  • J. Ahmadi et al.

    Monitoring of infectious intracranial aneurysms by sequential computed tomographic/magnetic resonance imaging studies

    Neurosurgery

    (1993)
  • N.S. Anavekar et al.

    Impact of prior antiplatelet therapy on risk of embolism in infective endocarditis

    Clin Infect Dis

    (2007)
  • D.J. Anderson et al.

    Stroke location, characterization, severity, and outcome in mitral vs aortic valve endocarditis

    Neurology

    (2003)
  • K. Angswurm et al.

    Timing the valve replacement in infective endocarditis involving the brain

    J Neurol

    (2004)
  • A. Autret et al.

    Neurological complications of endocarditis

  • A. Azuma et al.

    Brain magnetic resonance findings in infective endocarditis with neurological complications

    Jpn J Radiol

    (2009)
  • L.M. Baddour et al.

    Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America

    Circulation

    (2005)
  • L.M. Baddour et al.

    Update on cardiovascular implantable electronic device infections and their management. A scientific statement from the American Heart Association

    Circulation

    (2010)
  • J. Bamfort et al.

    Late rupture of a mycotic aneurysm after “cure” of bacterial endocarditis

    J Neurol

    (1986)
  • M. Baravelli et al.

    A case of Guillain–Barré syndrome following Staphylococcus aureus endocarditis

    Int J Cardiol

    (2007)
  • T.E. Bertonini et al.

    Magnetic resonance imaging of the brain in bacterial endocarditis

    Arch Intern Med

    (1989)
  • R.P. Beynon et al.

    Infective endocarditis

    BMJ

    (2006)
  • P. Bhuva et al.

    Intracranial hemorrhage following thrombolytic use for stroke caused by infective endocarditis

    Neurocrit Care

    (2010)
  • W.F. Bingham

    Treatment of intracranial mycotic aneurysms

    J Neurosurg

    (1977)
  • G.L. Bohmfalk et al.

    Bacterial intracranial aneurysms

    J Neurosurg

    (1978)
  • C.H. Cabell et al.

    The risk of stroke and death in patients with aortic and mitral valve endocarditis

    Am Heart J

    (2001)
  • K.L. Chan et al.

    Effects of long-term aspirin use on embolic events in infective endocarditis

    Clin Infect Dis

    (2008)
  • R. Chapot et al.

    Endovascular treatment of cerebral mycotic aneurisms

    Radiology

    (2002)
  • V.H. Chu et al.

    Early predictors of in-hospital death in infective endocarditis

    Circulation

    (2004)
  • J.Y. Chun et al.

    Current multimodality management of infectious intracranial aneurisms

    Neurosurgery

    (2001)
  • H.A. Cooper et al.

    Subclinical brain embolization in left-sided infective endocarditis: results from the evaluation by MRI of the brains of patients with left-sided intracardiac solid masses (EMBOLISM) pilot study

    Circulation

    (2009)
  • P. Corr et al.

    Endocarditis-related cerebral aneurysms: radiologic changes with treatment

    AJNR Am J Neuroradiol

    (1995)
  • I. Corral et al.

    Trends in neurological complications of endocarditis

    J Neurol

    (2007)
  • F. Delahaye et al.

    In-hospital mortality of infective endocarditis: prognostic factors and evolution over an 8-year period

    Scand J Infect Dis

    (2007)
  • S. Dhomne et al.

    Endovascular management of ruptured cerebral mycotic aneuryms

    Br J Neurosurg

    (2008)
  • A.F. Ducruet et al.

    Intracranial infectious aneurysms: a comprehensive review

    Neurosurg Rev

    (2010)
  • E. Durante Mangoni et al.

    Risk factors for “major” embolic events in hospitalized patients with infective endocarditis

    Am Heart J

    (2003)
  • X. Duval et al.

    Effect of early cerebral magnetic resonance imaging on clinical decisions in infective endocarditis: a prospective study

    Ann Intern Med

    (2010)
  • O. Epaulard et al.

    Infective endocarditis-related stroke: diagnostic delay and prognostic factors

    Scand J Infect Dis

    (2009)
  • Cited by (0)

    View full text