MULTI CASE REPORT
Role of echocardiograph in te dagnosis and management
of
infective endocarditis
H. Al Hashimi, N. Al Wimdy, J.C. McGhie, T.W. Galema, F.J. ten Cate, M.L. Simoons
Infective endocarditis is one of the most common causes of serious infection and carries a high risk of morbidity and mortality. It represents the fourth leading cause of life-threatening infections after urosepsis, pneumonia, and intra-abdominal sepsis. There is still a continuous rise in the incidence of infective endocarditis, with a rate of about 20,000 new cases in the United States alone.' This rise in incidence ofinfective endocarditis is mainly caused by increasing numbers of intravenous drug abusers, patients with artificial valves and elderly patients. In this paper, we will briefly review the crucial role of echocardiography in the diagnosis and management of infective endocarditis. (Neth Heart J 2004;12:64-8.) Key words: echocardiography, infective endocarditis, diagnosis and management, American Heart Association (AHA) guidelines W e present two patients in whom echocardiogw raphy was used in the diagnosis of infectious endocarditis. The first is a 52-year-old male with no significant previous medical history. An echocardiography was carried out (figure 1) and blood cultures were positive for Streptococcal bovis endocarditis. He was diagnosed with mitral valve endocarditis. A mitral valve replaceH. Al Hashimi Twente Medical Centre, Department of Cardiology, PO Box 50.000, 7500 KA Enschede N. Al Windy Department of Cardiology, Gelre Hospital/Spittaal, Ooyerhoekseweg 8, 7207 BA Zutphen
J.C. McGhle T.W. Galema F.J. ten Cate
M.L. Simoons Department of Cardiology, Thoraxcentre, Erasmus Medical Centre, Dr. Molewaterplein 40, 3015 GD Rotterdam
Correspondence to: H. Al Hashimi E-mail: [email protected]
64
ment was performed and intravenous antibiotics were administered. The patient suffered a haemorrhagic cerebrovascular accident (CVA). The second patient is a male, 20 years ofage, with a history of aortic (biscuspid) valve stenosis. His pressure gradient was 60 mmHg. The echocardiography is shown in figure 2. Blood cultures were positive for Staphylococcus aureus endocarditis. An aortic valve replacement was performed, using a homograft, and antibiotics were given. This patient also suffered a CVA (an infarct).
Diagnosis of Infective endocarditis Patients with endocarditis, especially the elderly, can present nonspecifically in various ways making diagnosis a bit tricky. Accurate and early diagnosis for initiation of effective treatment is essential for improving the patient's outcome. The variability in the clinical presentation ofinfective endocarditis means that a diagnostic strategy is needed which will be sensitive and specific for disease detection. In 1981, Von Reyn and his group were the first to propose clinical criteria (the Beth Israel criteria) for diagnosing infective endocarditis without including echocardiography as a diagnostic tool.2 Cases were identified as a definite infective endocarditis only if pathological confirmation from surgical or autopsy specimen was available. The major problem with these criteria is that only the minority of patients with infective endocarditis could be classified as definite cases, because less than one third of infective endocarditis patients require surgical intervention in the acute phase of their infection.3 Therefore, this classification has been criticised for not including clinical criteria as evidence of definite infective endocarditis.
Thirteen years later, in 1994, a new diagnostic strategy (the Duke criteria) was proposed by Durak and his group from Duke University. Durak and his group used echocardiography as a diagnostic tool along with clinical, microbiological and pathological findings in the clinical setting of infective endocarditis to provide a sensitive and specific approach to the diagnosis of infective endocarditis.3 Nctherlands Heart Journal, Volume 12, Number 2, Fcbruary 2004
Role of echocardiography in the diagnosis and management of infective endocarditis
Figure 1. TOE demonstrating a vegetation on the aortic valve and aortic valve regurgitation in a patient with acute aortic valve
infrctive endocarditis. Abbreviations: LA=left atrium, LV=left ventricle, V=vegetation, AV=atial valve, RJ=regurgitation Jet.
Figure 2. TOE demonstrating a large vegetation on the posterior mitral valve leaflet in a patient with acute mitral valve infretive endocarditis. Abbreviations: A=aorta, LA=left atrium, LV=leftventricek, V=vegetation.
Duke criteria for diagnosis of infective endocarditis The Duke criteria combined the Von Reyn clinical diagnostic parameters with the echocardiographic findings as shown in table 1. Clinically definite infective endocarditis according to the Duke criteria requires the presence of two major criteria, one major and three minor criteria or five minor criteria.4
Netherlands Heart Journal, Volume 12, Number 2, February 2004
Since the publication of the Duke criteria, a direct comparison with the Von Reyn criteria has been made in 11 major studies (in over 2000 patients). These studies confirmed an increased sensitivity and specificity for the Duke criteria, thus supporting the diagnostic use of echocardiography in the clinical setting of infective endocarditis.3 '3 Dodds and his group found 65
Role of echocardiography in the diagnosis and management of infective endocarditis
Table 1. Major criteria.4 1. Positive blood culture for infective endocarditis A. Typical micro-organism consistent with infective endocarditis from two separate blood cultures as noted below: - Viridans streptococci, Streptococcus bovis, HACEK group (Hemophilus parainfuenzae, Hemophilus aphrophilus, Actinobacillus, Actinomycetemitans, Cardiobacterium hominis, Eikenella species, and Kingella species) - Community-acquired Staphylococcus aureus or Enterococci, in the absence of a primary focus B. Micro-organism consistent with infective endocarditis from persistently positive blood cultures defined as: - .2 positive cultures of blood samples drawn >12 hours apart or - all of 3 or a majority of > 4 separate cultures of blood (with first and last sample drawn 2 1 hour apart)
2. Evidence of endocardial Involvement A. Positive echocardiogram for infective endocarditis defined as: - Oscillating intracardiac mass on valve (figures 1 and 2) or supporting structures, in the path of regurgitate jets, or on implanted material (figure 3) in the absence of an alternative anatomic explanation - Abscess - New partial valvular dehiscence of prosthetic valve B. New valvular regurgitation (worsening or changing murmur not sufficient)
Minor criteria4 1. Predisposition: predisposing heart condition or intravenous drug use 2. Fever: .38.00C 3. Vascular phenomena: embolic event, mycotic aneurysm, intracranial haemorrhage, conjunctival haemorrhage, and Janeway lesions 4. Immunological phenomena: glomerulonephritis, Osler's nodes, Roth spots, and rheumatoid factor 5. Microbiological evidence: positive blood culture but does not meet a major criterion as noted above 6. Echocardiographic findings: consistent with infective endocarditis but does not meet a major criterion as noted above
that the calculated negative predictive value ofthe Duke criteria was more than 98% in a study in which they followed up 52 consecutive patients in whom infective endocarditis was rejected for more than three months for a missed diagnosis or late development ofthe disease.7
Echocardiogram in diagnosis and management of infective endocarditis The role ofthe echocardiogram, whether transthoracic or transoesophageal, is not only limited to diagnosing infective endocarditis, it also plays an important role in defining the management strategy of infective endocarditis. By incorporating the echocardiogram we are able to diagnose infective endocarditis and its com-
plications such as valvular regurgitation, rupture, perforation and paravalvular extension (abscess and fistula). The echocardiogram is a useful tool in identifying the risk ofembolisation (table 2), which occurs in Table 2. Risk of embolisation.4
Figure 3. TOE demonstratinga large vegetation on the pacemaker wire in a patient with corrected transposition of the great vessel. Abbreviations: A=aorta, LV=left ventricle, V=vegetation, PA=pulmonary artery, RV=right ventricle.
66
1. The highest incidence of embolic complications is seen with left-sided endocarditis (mitral valve 25%, especially anterior leaflet, and the aortic valve 10%). 2. Left-sided vegetations that are >1 cm in diameter. 3. Infective endocarditis due to Staphylococus aureus, Candida sp, HACEK and Abiotrophia organism. 4. Patients with infective endocarditis and increasing vegetation size have a higher risk of embolic event (2x) compared with static or decreasing vegetation size.
Netherlands Heart Joumal, Volume 12, Number 2, February 2004
Role of echocardiography in the diagnosis and management of infective endocarditis
about 22 to 50% of cases of infective endocarditis, suggesting the potential need for surgical intervention (table 3).
Table 3. Potential need for surgical intervention.4
Vegetation - Anterior mitral leaflet vegetation, especially if it is larger
Transthoracic versus transoesophageal echocardiogram in the clinical setting Echocardiography is currently the primary tool for detecting vegetations and cardiac complications that result from endocarditis. Transoesophageal echocardiogram (TOE) has opened a new ultrasonographic window to the heart and has revolutionised the diagnosis and management of endocarditis and its complications, especially in patients with a prosthetic valve. TOE is technically superior to the transthoracic echocardiogram (ITEk) because of an improved signalto-noise ratio combined with a high resolution from high frequency transducers, and the lack of problems related to acoustic penetration through mechanical valves. For that reason, TOE is now considered a valuable method for assessing prosthetic valves. In general TOE plays an important additional role in facilitating the process ofmaking a correct diagnosis in the context of suspected infective endocarditis and the related complications. Several studies have been conducted comparing the sensitivity and specificity ofthe TOE versus TTE in the clinical setting ofinfective endocarditis (tables 4 and 5). These studies showed that TOE has a higher sensitivity (>95%) compared with TTE (
Role of echocardiograph in te dagnosis and management
of
infective endocarditis
H. Al Hashimi, N. Al Wimdy, J.C. McGhie, T.W. Galema, F.J. ten Cate, M.L. Simoons
Infective endocarditis is one of the most common causes of serious infection and carries a high risk of morbidity and mortality. It represents the fourth leading cause of life-threatening infections after urosepsis, pneumonia, and intra-abdominal sepsis. There is still a continuous rise in the incidence of infective endocarditis, with a rate of about 20,000 new cases in the United States alone.' This rise in incidence ofinfective endocarditis is mainly caused by increasing numbers of intravenous drug abusers, patients with artificial valves and elderly patients. In this paper, we will briefly review the crucial role of echocardiography in the diagnosis and management of infective endocarditis. (Neth Heart J 2004;12:64-8.) Key words: echocardiography, infective endocarditis, diagnosis and management, American Heart Association (AHA) guidelines W e present two patients in whom echocardiogw raphy was used in the diagnosis of infectious endocarditis. The first is a 52-year-old male with no significant previous medical history. An echocardiography was carried out (figure 1) and blood cultures were positive for Streptococcal bovis endocarditis. He was diagnosed with mitral valve endocarditis. A mitral valve replaceH. Al Hashimi Twente Medical Centre, Department of Cardiology, PO Box 50.000, 7500 KA Enschede N. Al Windy Department of Cardiology, Gelre Hospital/Spittaal, Ooyerhoekseweg 8, 7207 BA Zutphen
J.C. McGhle T.W. Galema F.J. ten Cate
M.L. Simoons Department of Cardiology, Thoraxcentre, Erasmus Medical Centre, Dr. Molewaterplein 40, 3015 GD Rotterdam
Correspondence to: H. Al Hashimi E-mail: [email protected]
64
ment was performed and intravenous antibiotics were administered. The patient suffered a haemorrhagic cerebrovascular accident (CVA). The second patient is a male, 20 years ofage, with a history of aortic (biscuspid) valve stenosis. His pressure gradient was 60 mmHg. The echocardiography is shown in figure 2. Blood cultures were positive for Staphylococcus aureus endocarditis. An aortic valve replacement was performed, using a homograft, and antibiotics were given. This patient also suffered a CVA (an infarct).
Diagnosis of Infective endocarditis Patients with endocarditis, especially the elderly, can present nonspecifically in various ways making diagnosis a bit tricky. Accurate and early diagnosis for initiation of effective treatment is essential for improving the patient's outcome. The variability in the clinical presentation ofinfective endocarditis means that a diagnostic strategy is needed which will be sensitive and specific for disease detection. In 1981, Von Reyn and his group were the first to propose clinical criteria (the Beth Israel criteria) for diagnosing infective endocarditis without including echocardiography as a diagnostic tool.2 Cases were identified as a definite infective endocarditis only if pathological confirmation from surgical or autopsy specimen was available. The major problem with these criteria is that only the minority of patients with infective endocarditis could be classified as definite cases, because less than one third of infective endocarditis patients require surgical intervention in the acute phase of their infection.3 Therefore, this classification has been criticised for not including clinical criteria as evidence of definite infective endocarditis.
Thirteen years later, in 1994, a new diagnostic strategy (the Duke criteria) was proposed by Durak and his group from Duke University. Durak and his group used echocardiography as a diagnostic tool along with clinical, microbiological and pathological findings in the clinical setting of infective endocarditis to provide a sensitive and specific approach to the diagnosis of infective endocarditis.3 Nctherlands Heart Journal, Volume 12, Number 2, Fcbruary 2004
Role of echocardiography in the diagnosis and management of infective endocarditis
Figure 1. TOE demonstrating a vegetation on the aortic valve and aortic valve regurgitation in a patient with acute aortic valve
infrctive endocarditis. Abbreviations: LA=left atrium, LV=left ventricle, V=vegetation, AV=atial valve, RJ=regurgitation Jet.
Figure 2. TOE demonstrating a large vegetation on the posterior mitral valve leaflet in a patient with acute mitral valve infretive endocarditis. Abbreviations: A=aorta, LA=left atrium, LV=leftventricek, V=vegetation.
Duke criteria for diagnosis of infective endocarditis The Duke criteria combined the Von Reyn clinical diagnostic parameters with the echocardiographic findings as shown in table 1. Clinically definite infective endocarditis according to the Duke criteria requires the presence of two major criteria, one major and three minor criteria or five minor criteria.4
Netherlands Heart Journal, Volume 12, Number 2, February 2004
Since the publication of the Duke criteria, a direct comparison with the Von Reyn criteria has been made in 11 major studies (in over 2000 patients). These studies confirmed an increased sensitivity and specificity for the Duke criteria, thus supporting the diagnostic use of echocardiography in the clinical setting of infective endocarditis.3 '3 Dodds and his group found 65
Role of echocardiography in the diagnosis and management of infective endocarditis
Table 1. Major criteria.4 1. Positive blood culture for infective endocarditis A. Typical micro-organism consistent with infective endocarditis from two separate blood cultures as noted below: - Viridans streptococci, Streptococcus bovis, HACEK group (Hemophilus parainfuenzae, Hemophilus aphrophilus, Actinobacillus, Actinomycetemitans, Cardiobacterium hominis, Eikenella species, and Kingella species) - Community-acquired Staphylococcus aureus or Enterococci, in the absence of a primary focus B. Micro-organism consistent with infective endocarditis from persistently positive blood cultures defined as: - .2 positive cultures of blood samples drawn >12 hours apart or - all of 3 or a majority of > 4 separate cultures of blood (with first and last sample drawn 2 1 hour apart)
2. Evidence of endocardial Involvement A. Positive echocardiogram for infective endocarditis defined as: - Oscillating intracardiac mass on valve (figures 1 and 2) or supporting structures, in the path of regurgitate jets, or on implanted material (figure 3) in the absence of an alternative anatomic explanation - Abscess - New partial valvular dehiscence of prosthetic valve B. New valvular regurgitation (worsening or changing murmur not sufficient)
Minor criteria4 1. Predisposition: predisposing heart condition or intravenous drug use 2. Fever: .38.00C 3. Vascular phenomena: embolic event, mycotic aneurysm, intracranial haemorrhage, conjunctival haemorrhage, and Janeway lesions 4. Immunological phenomena: glomerulonephritis, Osler's nodes, Roth spots, and rheumatoid factor 5. Microbiological evidence: positive blood culture but does not meet a major criterion as noted above 6. Echocardiographic findings: consistent with infective endocarditis but does not meet a major criterion as noted above
that the calculated negative predictive value ofthe Duke criteria was more than 98% in a study in which they followed up 52 consecutive patients in whom infective endocarditis was rejected for more than three months for a missed diagnosis or late development ofthe disease.7
Echocardiogram in diagnosis and management of infective endocarditis The role ofthe echocardiogram, whether transthoracic or transoesophageal, is not only limited to diagnosing infective endocarditis, it also plays an important role in defining the management strategy of infective endocarditis. By incorporating the echocardiogram we are able to diagnose infective endocarditis and its com-
plications such as valvular regurgitation, rupture, perforation and paravalvular extension (abscess and fistula). The echocardiogram is a useful tool in identifying the risk ofembolisation (table 2), which occurs in Table 2. Risk of embolisation.4
Figure 3. TOE demonstratinga large vegetation on the pacemaker wire in a patient with corrected transposition of the great vessel. Abbreviations: A=aorta, LV=left ventricle, V=vegetation, PA=pulmonary artery, RV=right ventricle.
66
1. The highest incidence of embolic complications is seen with left-sided endocarditis (mitral valve 25%, especially anterior leaflet, and the aortic valve 10%). 2. Left-sided vegetations that are >1 cm in diameter. 3. Infective endocarditis due to Staphylococus aureus, Candida sp, HACEK and Abiotrophia organism. 4. Patients with infective endocarditis and increasing vegetation size have a higher risk of embolic event (2x) compared with static or decreasing vegetation size.
Netherlands Heart Joumal, Volume 12, Number 2, February 2004
Role of echocardiography in the diagnosis and management of infective endocarditis
about 22 to 50% of cases of infective endocarditis, suggesting the potential need for surgical intervention (table 3).
Table 3. Potential need for surgical intervention.4
Vegetation - Anterior mitral leaflet vegetation, especially if it is larger
Transthoracic versus transoesophageal echocardiogram in the clinical setting Echocardiography is currently the primary tool for detecting vegetations and cardiac complications that result from endocarditis. Transoesophageal echocardiogram (TOE) has opened a new ultrasonographic window to the heart and has revolutionised the diagnosis and management of endocarditis and its complications, especially in patients with a prosthetic valve. TOE is technically superior to the transthoracic echocardiogram (ITEk) because of an improved signalto-noise ratio combined with a high resolution from high frequency transducers, and the lack of problems related to acoustic penetration through mechanical valves. For that reason, TOE is now considered a valuable method for assessing prosthetic valves. In general TOE plays an important additional role in facilitating the process ofmaking a correct diagnosis in the context of suspected infective endocarditis and the related complications. Several studies have been conducted comparing the sensitivity and specificity ofthe TOE versus TTE in the clinical setting ofinfective endocarditis (tables 4 and 5). These studies showed that TOE has a higher sensitivity (>95%) compared with TTE (
