ECHO 3 : Infective Endocarditis

what is infective endocarditis?

secondary invasion by bacteria, parasites, and fungi that causes infection of endocardium

(or other implanted intra cardiac materials like conduits, prosthetic implants, chamber walls)

what are common signs and symptoms of IE?

FROM JANE

fever

roths spots

osler’s nodes

murmur

janeway lesions

anemia

nail hemorrhage

emboli 

what is the dukes major criteria?

B : blood culture positive for IEA

E : imaging positive for IEA

• vegetation

• abscess

• pseudoanyeurysm 

what is duke’s minor criteria? 

1. predisposing heart conditions or IV drug use

2. fever

3. vascular phenomena

4. immunologic phenomena

5. microbiologic evidence

IV drug use affects

right side of heart (tricuspid valve) 

what are janeway lesions?

lesions on palms or soles caused by septic emboli which deposity bacteria forming microabscesses

how can echo distinguish between bacterial, viral and parasitic endocarditis?

echo can not 

what is the most common bacterial cause of IE? 

staphylococcus aureus 

how often can an echo be ordered for someone with suspected endocarditis?

if there are positive blood cultures then it can be ordered as many times as needed 

which modality is used to detect IE?

TTE first because it is non invasive (negative or inconclusive in 30% of cases) 

then TEE is performed because of better image quality and higher sensitivity 

how does IE present?

mobile vegetation

mobile vegetations of size - increases the risk of

>10mm

embolism

which sided vegetations are more common?

left sided vegetations are more common than right

vegetations are more common on sides where 

valves are exposed to high velocity regurgitant jets 

• LV side of AV

• LA side of MV

(mv vegetation on LV side which is not usual )

what is the upstream side of the valve?

the sides of the valves that are exposed to high regurg jets

how are IE vegetations formed?

from endothelial disruption caused by high velocity jets that accompany congenital defects, prosthetic valves, intracrdiac shunts, and valv dysfunction 

what is libman sacks endocarditis?

form of nonbacterial endocarditis associated with systemic lupus erythematosus 

what is the most common heart related manifestations of lupus?

pericarditis

what do IE vegetations look like?

irregularly shaped, low reflective structures that may be sessile (attached at base) or pedunculated 

color flow doppler is used to assess what in IE vegetations?

hemodynamic effect

does valvular endocarditis cause stenosis?

rarely

how do vegetations appear on MV

shaggy

partial obliteration of interleaflet separation

abnormal opening and closure times 

what is seen here?

tricuspid valve vegetation w/ severe regurg

what are other IE findings in the absence of vegetation?

abscesses

fistula

changes in prosthetic valve hemodynamics

valve dehiscence (splitting) 

paravalvular leaks 

what do IE abscesses look like?

nonhomogenous enclosed area appearing echolucent or echodense

which valve is most affected by endocarditic abscess?

ao valve (then mv) 

what is this?

abscess

what is shown here?

ao valve vegetation with abscess

what is seen here?

endocarditis vegetation of tricuspid leaflets and infectious abscess of aortic annulus 

what is seen here?

periannular absces adjacent to sewing ring 

what are the differential diagnosis for IE?

severe MAC 

• wonder if patient has fever or other signs of infection 

fibroelastoma

lambl’s excrescences

what is the most common benign neoplasm of cardiac valvular structures?

fibroelastoma 

fibroelastoma makes up - % of tumors in the heart

10

what is lambls excrescences

rare thin mobile and filiform cardiac growths that develop at heart valve closure sites

regurg secondary to valvular perforation often have

very steep deceleration slopes

review qs

vegetations are typically caused by

endocarditis 

• bacterial (staph) 

review qs

what are some differential diagnoses of a vegetation caused by infective endocarditis and how can one determine the diagnosis?

MAC, fibroelastoma, lambls excrensces

• look for signs of fever or other symptoms 

review q

vegetation on the right side of the heart would typically be caused by 

IV Drug use

review qs

which side of the heart are vegetations more likely to occur?

left