1. Endocardite Infectieuse : Rôle de l’Echocardiographie
21ème Congrès du Collège National des Cardiologues Français
Paris, 8-10 octobre 2009
Jean-Luc MONIN, CHU Henri Mondor, Créteil
Remerciements: Pr. Gilbert HABIB, CHU La Timone, Marseille

2. Diagnosis Management Role of Echocardiography
in Infective Endocarditis
Diagnosis
Management

3. Diagnosis Management Role of Echocardiography
in Infective Endocarditis
Diagnosis
Management

4. Modified Duke criteria for the diagnosis of Infective Endocarditis
MAJOR CRITERIA:
- Blood cultures positive for IE
- Echocardiography positive for IE: vegetation, abscess, new valvular regurgitation/ dehiscence of prosthetic valve
MINOR CRITERIA:
- Predisposing heart condition, IV drug abuse
- Fever (> 38°C)
- Vascular phenomena: arterial emboli, mycotic aneurysms, intracranial hemorrhage, …
- Immunologic phenomena: Osler’s nodes, Roth’s spots, …
- Bacteriological evidence: Positive blood culture but does not meet major criteria
Li et al. Clin Infect Dis. 2000; 30: 633-8

5. Clinical Suspicion of IE
Trans-thoracic Echocardiography
Prosthetic Valve
Intracardiac
device
Poor quality
TTE
Positive
TTE
TTE Negative
Clinical suspicion of IE
High
Low
Transesophageal Echocardiography *
Stop
If initial TEE is negative but suspicion for IE remains, repeat TEE within 7-10 days
Habib et al. ESC Guidelines. Eur Heart J Aug 27

6. Diagnosis of Infective Endocarditis by Echo:
Difficulties are frequent…
Diagnosis of vegetation
Diagnosis of abscess
IE affecting intra-cardiac devices

7. Diagnosis of vegetation
Diagnosis of Infective Endocarditis by Echo:
Difficulties are frequent…
Diagnosis of vegetation
Diagnosis of abscess
IE affecting intra-cardiac devices

8. Diagnostic value for detecting vegetations: TTE versus TEE
- In 80 cases of endocarditis, sensitivity for the detection of vegetation was 58% for TTE versus 90% for TEE (p= 0.001).
Mugge et al. J Am Coll Cardiol. 1989; 14: 631-8
Sensitivity (%)
Specificity (%)
Accuracy (%)
Vegetations
TTE (n=281)
TEE (n=269)
79%
83% *
98%
99%
97%
* P= NS : TTE versus TEE
Monin et al. J Am Coll Cardiol. 2005; 46: 302-9

9. Henri Mondor
Apical 4-chamber view
Nunes

10. Apical 4-chamber (Lower plane)
Henri Mondor
Apical 4-chamber (Lower plane)
Nunes

11. Henri Mondor
Color Flow Doppler
Commissural leak (C2)
Nunes

12. Clinical Suspicion of IE
Trans-thoracic Echocardiography
Prosthetic Valve
Intracardiac
device
Poor quality
TTE
Positive
TTE
TTE Negative
Clinical suspicion of IE
High
Low
Transesophageal Echocardiography *
Stop
If initial TEE is negative but suspicion for IE remains, repeat TEE within 7-10 days
Habib et al. ESC Guidelines. Eur Heart J Aug 27

13. TEE : Inter-commissural plane
Henri Mondor
TEE : Inter-commissural plane
Nunes

14. Inter-commissural plane + CFD
Henri Mondor
Inter-commissural plane + CFD
Nunes

15. A negative TEE does not rule out endocarditis
Echocardiography (even Transesophageal)
is not 100% sensitive
Very small (< 2 mm) vegetation
Non vegetant endocarditis
Prosthetic and pacemaker endocarditis
Mitral valve prolapse with thickened valves
Vegetation not yet present or already embolized
A negative TEE does not rule out endocarditis
If initial TEE is negative but suspicion for IE remains, repeat TEE within 7-10 days
Habib et al. ESC Guidelines. Eur Heart J Aug 27

16. Diagnosis of abscess Diagnosis of Infective Endocarditis by Echo:
Difficulties are frequent…
Diagnosis of vegetation
Diagnosis of abscess
IE affecting intra-cardiac devices

17. Abscess of the aortic root
- Better assessed by TEE
- Multiple views to assess
abscess extension
- Difficult diagnosis at the early stage of the disease
- Need for frequent TEE controls if non operated
Courtesy: Pr. C. Tribouilloy

18. Abscess of the aortic root: Better assessed by TEE
Courtesy: Pr. C. Tribouilloy

19. Abscess of the aortic root: Better assessed by TEE
Courtesy: Pr. C. Tribouilloy

20. Diagnosis of abscess Diagnosis of Infective Endocarditis by Echo:
Difficulties are frequent…
Diagnosis of vegetation
Diagnosis of abscess
IE affecting intra-cardiac devices

21. Prosthetic valve endocarditis
- Better assessed by TEE
- Especially in the mitral position
- Reverberations/ artifacts due to the prosthesis
- Need for frequent TEE controls if non operated
Postoperative D-45

22. Prosthetic valve endocarditis:
The role of Transesophageal Echo
Postoperative D-45

23. Adapted antibiotics (D+10)
Prosthetic valve endocarditis:
Repeat TEE if non operated
Adapted antibiotics (D+10)

24. Adapted antibiotics (D+10)
Prosthetic valve endocarditis
Adapted antibiotics (D+10)

25. Diagnosis Management Role of Echocardiography
in Infective Endocarditis
Diagnosis
Management

26. Timing of Surgery in Infective Endocarditis: The 2009 ESC Guidelines
INDICATIONS FOR SURGERY
Timing
Class
Level
A/ CONGESTIVE HEART FAILURE
Severe acute AR or MR or valve obstruction causing refractory pulmonary oedema / cardiogenic shock
Emergency I B
Aortic or mitral IE with fistula causing refractory pulmonary oedema or cardiogenic shock
Severe acute AR or MR or valve obstruction with persistent CHF or echocardiographic signs of poor hemodynamic tolerance (early mitral closure, pulmonary hypertension)
Urgent
Severe acute AR or MR without CHF or any sign of poor tolerance
Elective
IIa
B/ UNCONTROLLED INFECTION
Locally uncontrolled: enlarging vegetation, abscess, fistula, false aneurysm)
Persisting fever and positive blood cultures > 7-10 days of antibiotics
IE due to fungi or multi resistant organisms
Urgent/ Elective
C/ PREVENTION OF EMBOLISM
Large aortic or mitral vegetations (>10 mm) following ≥1 embolic episode despite appropriate antibiotics
Large aortic or mitral vegetations (>10 mm) with other predictors of complicated course (CHF, persistent infection, abscess) C
Very large vegetations without any other risk factors
IIb

27. Timing of Surgery in Infective Endocarditis:
Indications for Uncontrolled Infection
Indications for Surgery
Timing *
Class
Level
Locally uncontrolled: enlarging vegetation, abscess, fistula, false aneurysm)
Urgent I B
Persisting fever and positive blood cultures > 7-10 days of antibiotics
IE due to fungi or multi resistant organisms
Urgent/ Elective
ESC Guidelines. Eur Heart J Aug 27

28. Emergent surgery (the same day): Acute severe AR with pulmonary oedema
Early mitral closure

29. Emergent surgery (the same day): Acute severe AR with pulmonary oedema
Diastolic MR

30. Acute severe AR with pulmonary oedema :
Limitations of the PHT

31. Timing of Surgery in Infective Endocarditis:
Indications for Heart Failure
Indications for Surgery
Timing *
Class
Level
Severe acute Aortic or mitral regurgitation or valve obstruction causing refractory pulmonary oedema or cardiogenic shock
Emergency
(within 24 Hours) I B
Aortic or mitral IE with fistula causing refractory pulmonary oedema or cardiogenic shock
Severe acute AR or MR or valve obstruction with persistent CHF or echocardiographic signs of poor hemodynamic tolerance (early mitral closure, pulmonary hypertension)
Urgent
(within 2-3 days)
Severe acute Aortic or mitral regurgitation without CHF or any sign of poor tolerance
Elective
IIa
ESC Guidelines. Eur Heart J Aug 27

32. Risk of systemic embolism according to Vegetation size (TEE)
9/45
17/66
10/24
30/43
178 patients, definite IE
% Embolic events
Di Salvo et al. J Am Coll Cardiol. 2001; 37:

33. Risk of systemic embolism under appropriate antibiotics
384 patients with definite IE , European multicentre study
Embolic events: n= 131 (34%), of which 28 (7.3%) under therapy
Under therapy: 20 events (71.4%) during the first 15 days
% New Embolic Events
Thuny et al. Circulation. 2005; 112: 69-75

34. THE RISK OF EMBOLIC EVENTS:
Risk of systemic embolism
under appropriate antibiotics
629 cases of IE, 133 embolic events (21.1 %)
THE RISK OF EMBOLIC EVENTS:
Dramatically decreases after initiation of ATB
Remains high during the first 2 weeks of ATB
Is related to the size /mobility of the vegetations
May be reduced by early surgery ?
Fabri et al. Int J Cardiol ; 110 : 334-9

35. Timing of Surgery in Infective Endocarditis : Prevention of embolism
Indications for Surgery
Timing *
Class
Level
Large aortic or mitral vegetations (>10 mm) following ≥1 embolic episode despite appropriate antibiotics
Urgent
(within 2-3 days) I B
Large aortic or mitral vegetations (>10 mm) with other predictors of complicated course : (CHF, persistent infection, abscess) C
Very large vegetations without any other risk factors
IIb
ESC Guidelines. Eur Heart J Aug 27

36. Isolated large vegetation > 15 mm:
Urgent surgery is required (Class IIb)

37. Take-Home messages
Echocardiography plays a key role in the diagnosis and management of patients with infective endocarditis
Transesophageal echo is mandatory in the majority of patients
A negative TEE does not rule out endocarditis: repeat TEE after 7-10 days if suspicion if IE remains
Early indications for surgery (CHF, uncontrolled infection or prevention of embolism) are mainly based on echocardiography (TEE ++)