Key points
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Vegetations are oscillating or nonoscillating intracardiac masses on the valves or other endocardial structures or intracardiac implanted materials.
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Vegetations are typically located on the upstream side of the valves, are usually irregularly and grotesquely shaped, and exhibit disordered motions that are not in pattern with the excursion of the valve leaflets.
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Abscesses are thick, nonhomogeneous, echolucent, or echodense perivalvular areas.
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Three echocardiographic findings are considered to be major criteria for the diagnosis of endocarditis: (1) the presence of vegetations, (2) the presence of abscesses, and (3) the presence of new dehiscence in a valvular prosthesis ( Algorithm 7.1 , Figs. 7.2–7.4 , Tables 7.5 and 7.6 , Figs. 7.7–7.9 , Table 7.10 ).
Algorithm 7.1
The image depicts the approach to IE . IE , infective endocarditis; TTE , transthoracic echocardiography; TEE , transesophageal echocardiography.
Fig. 7.2
Transesophageal echocardiography in a patient with mitral valve endocarditis shows a large, mobile, shaggy, bizarre-shaped mass on the anterior mitral valve leaflet (A and B), which has resulted in the malapposition of the leaflets and a severe, eccentric-jet, posterolaterally directed mitral regurgitation (C). A 3D zoom reconstruction of the mitral valve mass is depicted in section (D, black arrow ). The mass characteristics and clinical findings are compatible with infective endocarditis, as documented by Staphylococcus aureus growth in postsurgical specimen growth.
Fig. 7.3
The image illustrates the transesophageal echocardiographic examination of a patient with a bicuspid aortic valve (mediolateral orientation). There is a shaggy, semimobile echodensity attached to the tip of the medial leaflet (B, white arrow ). The valve is destructed with the perforation and flail of the lateral leaflet (C, white arrow ).
Fig. 7.4
Transesophageal echocardiography in a patient with aortic bioprosthesis shows a large, semimobile, oval-shaped echodensity on the right cusp of the aortic bioprosthesis (white arrows) . The postsurgical specimen confirmed fungal endocarditis with Candida albicans .
Table 7.5
Risk factors for fungal endocarditis.
Risk factors for fungal endocarditis
Intravenous drug abuse
Prolonged antibiotic therapy
Prolonged indwelling central venous catheter
Prosthetic heart valve
Previous history of endocarditis
Parenteral nutrition
Neutropenia
Diabetes mellitus
Table 7.6
Clinical significance of fungal endocarditis.
Clinical significance of fungal endocarditis
Fungal endocarditis is a very devastating disease
Timely diagnosis is the key, because it presents mostly with general constitutional symptoms; high index of suspicion is required for early diagnosis. Induction treatment followed by suppressive therapy (in selected patients) is key to management
Surgical replacement of the infected valve is a class I recommendation
Fig. 7.7
Transthoracic echocardiography in the parasternal long-axis view shows a large, hypermobile, oval-shaped, hyper echo mass attached to the atrial side of the base of the anterior mitral valve leaflet, which protrudes into the left ventricle in the diastole. The mass is a large fungal vegetation in an intravenous drug abuser presenting with fever and malaise. The mass has a high probability for endocarditis complications, including valve destruction, mitral stenosis, regurgitation, abscess formation, and systemic embolism ( Supplementary Video 7.S1 ). Fungi account for fewer than 10% of infective endocarditis cases, with native valve fungal endocarditis being even less common. Approximately, 24% of fungal endocarditis cases are caused by Candida albicans . It is usually seen in patients with valvular disease, intravenous drug use, indwelling vascular lines, or immunocompromised states. Echocardiography cannot distinguish fungal vegetations from other microorganisms definitely; nevertheless, a dense, hyperechoic, large mass (≈ 2 cm) in the relevant clinical setting can be in favor of a fungal vegetation. Overall, patients with fungal endocarditis have a poor prognosis, and left-sided fungal endocarditis, acute heart failure, and exclusive medical treatment are independent risk factors for mortality .
Transthoracic echocardiography in the parasternal long-axis view shows a large, hypermobile, oval-shaped, hyper echo mass attached to the atrial side of the base of the anterior mitral valve leaflet, which protrudes into the left ventricle in the diastole. The mass is a large fungal vegetation in an intravenous drug abuser presenting with fever and malaise. The mass has a high probability for endocarditis complications, including valve destruction, mitral stenosis, regurgitation, abscess formation, and systemic embolism (Supplementary Video 7.S1 in the online version at https://doi.org/10.1016/B978-0-323-84906-7.00006-6 ). Fungi account for fewer than 10% of infective endocarditis cases, with native valve fungal endocarditis being even less common. Approximately, 24% of fungal endocarditis cases are caused by Candida albicans . It is usually seen in patients with valvular disease, intravenous drug use, indwelling vascular lines, or immunocompromised states. Echocardiography cannot distinguish fungal vegetations from other microorganisms definitely; nevertheless, a dense, hyperechoic, large mass (≈ 2 cm) in the relevant clinical setting can be in favor of a fungal vegetation. Overall, patients with fungal endocarditis have a poor prognosis, and left-sided fungal endocarditis, acute heart failure, and exclusive medical treatment are independent risk factors for mortality .
Fig. 7.8
The figures reveal tricuspid valve infective endocarditis in transthoracic echocardiography. (A) Echocardiography in the apical 4-chamber view in a 38-year-old woman on hemodialysis presenting with prolonged fever shows a shaggy, mobile vegetation on the tricuspid valve oscillating between the right ventricle and the right atrium. (B) Echocardiography in the parasternal short-axis view in a young intravenous drug abuser reveals tricuspid valve vegetations. The differential diagnosis of these vegetations is the tricuspid valve tumor.
Fig. 7.9
Transesophageal echocardiography in 2 patients with hydatid cysts. There is a large, round-shaped cystic mass, with an echolucent center attached to the base of the left ventricular lateral wall (B and C, black arrows ). This mass is accompanied by a similar lesion in the liver (A, white arrow ), which suggests cardiac and hepatic hydatid cysts. A large, globular cystic lesion with a central opacity is seen attached to the left ventricular apicoseptal segment, in favor of a hydatid cyst with a daughter cyst within it. Cardiac hydatid cysts are uncommon, with the dominant involvement of the left ventricle. The cysts may grow and lead to compression effects on the adjacent myocardium, resulting in coronary vessel involvement, rhythm disturbances, and interference with valvular and ventricular function. Echocardiography is the method of choice for the assessment of cardiac hydatidosis .
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