2. Overview
Background
Diagnosis
ACC/AHA indications for Echo
TTE versus TEE
Diagnostic Echo criteria
Echocardiographic estimation of outcome
Intracardiac complications of endocarditis
3. Background
Infection of endocardium
valve leaflets, congenital defects, chamber walls
or chordae, prosthetic valves/conduits
4. Background
Infection of endocardium
valve leaflets, congenital defects, chamber walls
or chordae, prosthetic valves/conduits
Diagnosis: modified Duke criteria
No noninvasive technique can definitively
diagnose
Echocardiography has high sensitivity for IE and
intracardiac abscess
Mandatory in the diagnosis and treatment of IE
5. Goals of Echo in Possible IE
Identify, localize, and characterize masses consistent with vegetations
Identify new valvular regurgitation
Examine prosthetic valve stability
Apply criteria to judge prognosis once vegetation identified
16. Diagnostic Echo criteria
Characteristics of mass likely to be a vegetation:
Texture: gray scale and reflectance of myocardium
Location: upstream side of valve in path of jet or on
prosthetic material
17.
18. TTE vs TEE for
VEGETATIONS TTE is initial diagnostic test
TTE can miss vegetation < 0.5cm in size
TTE vs TEE sensitivity 40-63% vs 90-99%,
specificity 90-98% vs 91-99%
Repeat TEE after 7-10 days in patients with strong suspicion of vegetation
19.
20. OBJECTIVES OF ECHO FOR
VEGETATIONS
I. Detection of cardiac vegetation
II. Demonstration of local complications
III. Diagnosis of predisposing lesions
IV. Evaluation of responses to treatment
V. Proper timing of surgical intervention
21. ECHO FEATURES OF
ENDOCARDITIS
1. Detection
2. Site
3. Size
4. shape
5. Echogenecity
6. Mobility
7. Differentiation from different masses
22. 1. DETECTION
2D – mobile, irregular,
echogenic, attached to
valve cusp or cardiac lesion
and prolapsing in one of
chambers
M- mode : thick dense,
irregular multiple echoe
lines seen on one or more
valve leaflets
23. 2. SITE
It depends on underlying cardiac lesion
MR – LA
AR – LVOT
VSD - RV
24. 3. SIZE
2 - 20mm
<2mm difficult to visualize –TEE
Large vegetation associated with fungal /tricuspid
Getting smaller in size – heal
- embolization
Mitral > aortic vegetation
27. 6. MOBILITY
High – large /pedunculated vegetation
Low – small/sessile vegetation
28. 7. DIFFERENTIATION FROM
OTHER MASSES
Difficult to differentiate from these :
Myxomatous changes in floppy valve
Thrombus formation in prosthetic valve
Calcified nodules on thick Rheumatic Valve
34. II. DETECTION OF LOCAL
COMPLICATION Spread of endocarditis on
– on other valve
- on other parts of valve leaflets/chordea
HF from associated myocarditis, pericardial effusion, acute valvular
regurgitation
Abscess formation –rupture of sinus of valsalva – L to R shunt
Valvular regurgitation - rupture/ perforation/ prolapse/
abscess formation
37. V. PROPER TIMING OF SURGICAL
INTERVENTION
1. CHF secondary to valvular insufficiency, refractory to
medical therapy
2. Fungal IE
3. Persistent sepsis>72 hrs despite of appropriate
medical therapy
4. Valve dehiscence, rupture, abscess, fistula
5. AML infection in setting of Aortic Valve IE
6. Heart block caused by abcess
7. Prosthetic valve endocarditis
8. Highly mobile, large >10mm vegetation
38. Diagnostic Echo criteria
Characteristics of mass likely to be a vegetation:
Texture: gray scale and reflectance of myocardium
Location: upstream side of valve in path of jet or on
prosthetic material
Motion: choatic and orbiting, independent of valve
motion
Prolapse into upstream chamber (i.e. MV mass into LA in systole)
39.
40. Diagnostic Echo criteria
Characteristics of mass likely to be a vegetation:
Texture: gray scale and reflectance of myocardium
Location: upstream side of valve in path of jet or on
prosthetic material
Motion: choatic and orbiting, independent of valve
motion
Prolapse into upstream chamber (i.e. MV mass into LA in systole)
Shape: lobulated, amorphous
Accompanying abnormalities:
abscess, pseudoaneurysm, fistula, prosthetic dehiscence,
paravalvular leak, new regurgitant lesion
41. Diagnostic Echo criteria
Characteristics of mass unlikely to be vegetation:
Texture: reflectance of calcium or pericardium (white)
Location: outflow tract attachment, downstream surface
of valve
Shape: stringy or hair-like strands with narrow
attachment
Lack of accompanying turbulent flow or regurgitation
42. False Positives
Most common on TEE
Lambl’s excrescences
Strands on sewing rings of prosthetics
Free suture
Redundant chordae, false tendons in LV
Chiari’s remnant in RA
Chordal insertion into normal MV
All of above tend to be highly reflective with
echodensity similar to pericardium or aortic root.
Dense, fibrotic, non-vibratory nature
54. False Negatives
TTE>TEE
High sensitivity of TEE (92-94%)
Cannot definitively rule out endocarditis
Low likelihood of IE if negative TEE in
intermediate probability patient
In patients at high risk for IE (prosthetic valve,
unexplained bacteremia), repeat examination
reasonable
55. Intracardiac Complications
Valvular regurgitation
Secondary infection of other valves
Leaflet perforation
Perivalvular abscess or fistula
Early invasion cellulitis (echodense thickening of perivalvular tissue)
Necrosis and inflammation abscess cavity
Abscess most likely with staph aureus
Risk of fistula formation
Abscess formation increase in morbidity and mortality
TEE >TTE: 118 pts with IE, 1991, 44 with abscess at surgery/autopsy. 87%
vs 28% sensitivity*
TEE still imperfect. Additional series 2007 showed TEE detecting only 48%
of abscesses (21 of 44 pts)+
*Daniel, WG, Mugge, A, Martin, RP, et al. Improvement in the diagnosis of abscesses associated with endocarditis by transesophageal
echocardiography. N Engl J Med 1991; 324:795.
+Hill, EE, Herijgers, P, Claus, P, et al. Abscess in infective endocarditis: the value of transesophageal echocardiography and outcome:
a 5-year study. Am Heart J 2007; 154:923.
