Endocarditis

Endocarditis is an inflammatory reaction of the endocardium. It usually involves the heart valves. It can be divided in infectious and non-infectious causes, depending on whether there is a micro-organism involved in the process. There are several manifestations of endocarditis:

Vegetation (most common and direct evidence of endocarditis).

• Leaflet destruction/perforation.

• Abscess/aneurysm formation.

• Fistula formation.

• Dehiscence of prosthetic valve.

 

Vegetation tricuspid valve

Abces aortic root

 

Infectious endocarditis

The heart valves do not receive any blood supply, so leukocytes can not reach the valves via the bloodstream. Normally, the blood flow prevents such infections. However, if the valve is damaged, for example by rheumatic fever or after a surgery, it is much easier exposed to pathogens.. Inflammation in the mouth, for example by poor oral hygiene, is a major cause of endocarditis. Usually streptococcal species are found as a pathogen. Another group is formed by the staphylococci which are located on the skin and are often the cause of endocarditis in as intravenous drug users. The risk of endocarditis is increased in patients with prosthetic valves and cardiac implantable electronic devices. Diagnosis of infective endocarditis according to the modified Duke criteria (ESC guidelines 2015).

The diagnosis of infective endocarditis is made in the presence of at least:

• 2 major criteria.

• 1major and 3 minor criteria.

• 5 minor criteria.

 

Therapy The main treatment in infective endocarditis consist of prolonged administration of antimicrobial drugs. Surgery is indicated in patients with heart failure, uncontrolled infection or as prevention of systemic embolism.

Click here for guidelines Endocarditis prophylaxis of the Dutch Heart Foundation.

 

Non-infectious endocarditis

A non-infectious endocarditis is very rare. One form of non-infectious endocarditis is called Libman–Sacks endocarditis and is especially common in patients with lupus erythematosus and antiphospholipid syndrome. Non-infective endocarditis may also occur in some forms of cancer. Loffler’s endocarditis Loffler’s endocarditis also known as eosinophilic endocarditis, endomyocardial disorder or fibroblastic endocarditis is a form of the hypereosinophilic syndrome (HES) in which the heart is predominant involved It is an unusual myocardial fibrosis disorder characterized by a thickening of the endocardium in one or both ventricles. In 1936 the Swiss physician Dr. Wilhelm Loffler (1887-1972) described this progressive heart disease for the first time, and has adopted it as a non–malignant disease. Cardiac manifestations occur in 50-60% of HES patients. The endocardial layer of one or both ventricles is thickened and has an influence on the underlying myocardium. Large mural thrombi can be developed with a reduction of the LV lumen and are a potential source for embolism. An overview of the echocardiographic characteristics of Loffler’s endocarditis is listed below. Further very little is know about this disease.

 

Echocardiographic features

• Endocardium thickening.

• Apical obliteration.

• Hyper echogenic mass suggestive of fibrosis or thrombus.

• Hyper dynamic contraction of the uninvolved ventricle.

• Biatrial dilatation.

• Restrictive filling pattern.

 

 

Lofflers endocarditis with fibrotic mass in LV

 

 

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