2. Colonization or invasion of the heart valves orColonization or invasion of the heart valves or
mural endocardium by a microbemural endocardium by a microbe
Leads to the development of bulky friableLeads to the development of bulky friable
vegetationsvegetations
Vegetations : Composed ofVegetations : Composed of
thrombotic debris,thrombotic debris,
micro-organismsmicro-organisms
+/- ass. damage of underlying cardiac tissue+/- ass. damage of underlying cardiac tissue
Usually bacterial ( a.k.a bacterial endocarditis).Usually bacterial ( a.k.a bacterial endocarditis).
May be acute or subacuteMay be acute or subacute
3. ACUTE INFECTIVEACUTE INFECTIVE
ENDOCARDITISENDOCARDITIS
SUBACUTESUBACUTE
ENDOCARDITISENDOCARDITIS
(SABE)(SABE)
BacteriaBacteria Very virulent.Very virulent.
Eg : Staph.aureusEg : Staph.aureus
Low virulenceLow virulence
Eg : Strep viridansEg : Strep viridans
Valves beforeValves before
infectioninfection
NormalNormal DiseasedDiseased
DurationDuration Days to weeksDays to weeks Insidious onset.Insidious onset.
Protracted courseProtracted course
LesionLesion Severe infection -Severe infection -
Nerotising, ulcerativeNerotising, ulcerative
Less destructive,Less destructive,
Likely to healLikely to heal
OutcomeOutcome FatalFatal Heals but withHeals but with
complicationscomplications
TreatmentTreatment No response toNo response to
antibiotics.antibiotics.
Requires surgeryRequires surgery
Responds to antibioticsResponds to antibiotics
5. Causative organismsCausative organisms
In previously damaged valves:In previously damaged valves:
streptococcus viridansstreptococcus viridans (50-60%)(50-60%)
In normal or damaged valves, IV drugIn normal or damaged valves, IV drug
abusers:abusers: S aureusS aureus (10-20%)(10-20%)
EnterococciEnterococci
HACEKHACEK Group of oral commensalsGroup of oral commensals
((HHaemophilus,aemophilus, AActinobacillus,ctinobacillus,
CCardiobacterium,ardiobacterium, EEikenella,ikenella, KKingella)ingella)
Coagulase neg staphCoagulase neg staph: prosthetic valve: prosthetic valve
infectioninfection
6. Other agents: fungi, gram neg bacilliOther agents: fungi, gram neg bacilli
In 10% Culture is negative. No organismIn 10% Culture is negative. No organism
can be isolatedcan be isolated
SOURCES OF ENTRY OF INFECTIONSOURCES OF ENTRY OF INFECTION
Infection elsewhereInfection elsewhere
Dental or surgical procedureDental or surgical procedure
IV drug abuseIV drug abuse
Occult sources in Gut, oral cavity etc.Occult sources in Gut, oral cavity etc.
7. PATHOGENESISPATHOGENESIS
Damaged valves are more prone to bacterial infectionDamaged valves are more prone to bacterial infection
Hemodynamic stressHemodynamic stress
Damaged endotheliumDamaged endothelium
Platelet thrombiPlatelet thrombi
Bacterial infectionBacterial infection
BE / IEBE / IE
9. SITESITE
Valves : Most common : mitral, aorticValves : Most common : mitral, aortic
IV abusers : Tricuspid, pulmonaryIV abusers : Tricuspid, pulmonary
EndocardiumEndocardium
GROSSGROSS
VEGETATIONSVEGETATIONS
Single/ multipleSingle/ multiple
1 or more valves involved1 or more valves involved
Friable, bulky, destructiveFriable, bulky, destructive
Erode adjacent myocardiumErode adjacent myocardium
SABE : no erosion, perforationSABE : no erosion, perforation
RING abscess.RING abscess.
APPEARANCE DEPENDS
UPON
1. Type of organism
BE : Bulky
SABE : Smaller
Fungal : Larger
2. Degree of host response
3. Previous antibiotic therapy
10. vegetations are composed of fibrin,vegetations are composed of fibrin,
inflammatory cells, bacteria and otherinflammatory cells, bacteria and other
organismsorganisms
17. NBTENBTE
Characterised by deposition of small masses of fibrin, platelets, andCharacterised by deposition of small masses of fibrin, platelets, and
other blood components on the leaflets of cardiac valves.other blood components on the leaflets of cardiac valves.
VegetationsVegetations
Sterile, nondestructiveSterile, nondestructive
Small (1-5mm)Small (1-5mm)
Along line of closure of the leaflets or cuspsAlong line of closure of the leaflets or cusps
On either side of leafletsOn either side of leaflets
Occurs in debilitated patients (marantic)Occurs in debilitated patients (marantic)
May be due to hypercoagulable states that occur inMay be due to hypercoagulable states that occur in
association with cancerassociation with cancer
Eg : Mucinous AdenoCa pancreasEg : Mucinous AdenoCa pancreas
AML – M3AML – M3
Indwelling catheter – endocardial traumaIndwelling catheter – endocardial trauma
18. Libman Sacks EndocarditisLibman Sacks Endocarditis
endocarditis of SLEendocarditis of SLE
Small medium sized vegetations on either or both
sides of the valve
19. Endocarditis of SLE (LSE)Endocarditis of SLE (LSE)
Small sterile (bland) vegetations on mitralSmall sterile (bland) vegetations on mitral
and tricuspid valvesand tricuspid valves
On undersurface of AV valvesOn undersurface of AV valves
Valvular endocardiumValvular endocardium
ChordsChords
Mural endocardium of ventricles or atriaMural endocardium of ventricles or atria
Micro :Micro :
Granular fibrinous materialGranular fibrinous material
Hematoxyphilic bodiesHematoxyphilic bodies
Fibrinoid necrosisFibrinoid necrosis
21. Pathological criteriaPathological criteria
Microorganisms demonstrated by cultureMicroorganisms demonstrated by culture
or histological examination. Found in aor histological examination. Found in a
vegetation, embolus from a vegetation, orvegetation, embolus from a vegetation, or
intracardiac abscessintracardiac abscess
Histological confirmation of activeHistological confirmation of active
endocarditis in a vegetation or intracardiacendocarditis in a vegetation or intracardiac
abscessabscess
23. Major clinical criteriaMajor clinical criteria
Positive blood culturePositive blood culture
ECG findings of mass or abscessECG findings of mass or abscess
New valvular regurgitationNew valvular regurgitation
24. MINOR CRITERIAMINOR CRITERIA
FeverFever
Predisposing heart lesion, IV drug abusePredisposing heart lesion, IV drug abuse
Vascular lesionsVascular lesions
Immunological phenomenaImmunological phenomena
Microbiological evidenceMicrobiological evidence
ECG findings consistent but not diagnosticECG findings consistent but not diagnostic
of IEof IE
25. Vascular lesionsVascular lesions
Arterial petechiaeArterial petechiae
Subungual /splinter hemorrhagesSubungual /splinter hemorrhages
Emboli, septic infarctsEmboli, septic infarcts
Mycotic aneurysmMycotic aneurysm
Janeway lesions( Small erythematousJaneway lesions( Small erythematous
lesions on palms and soles due to septiclesions on palms and soles due to septic
emboli)emboli)
27. Immunological phenomenaImmunological phenomena
GlomerulonephritisGlomerulonephritis
Oslers nodesOslers nodes: small tender subcutaneous: small tender subcutaneous
nodules in the pulp of the digitsnodules in the pulp of the digits
Roths spotsRoths spots: Oval retinal hemorrhages: Oval retinal hemorrhages
with pale centreswith pale centres
28. For diagnosisFor diagnosis
Either pathological criteriaEither pathological criteria
If clinical criteria are usedIf clinical criteria are used
• 2 major2 major
• 1 major and 3 minor1 major and 3 minor
• 5 minor criteria for diagnosis5 minor criteria for diagnosis
30. CATEGORIESCATEGORIES
Malformations associated with left to rightMalformations associated with left to right
shuntsshunts
Malformations associated right to leftMalformations associated right to left
shunts (cyanotic heart disease)shunts (cyanotic heart disease)
Malformations associated with obstructionMalformations associated with obstruction
31.
32.
33.
34. Tetralogy of Fallot (TOF)Tetralogy of Fallot (TOF)
The most common congenital cyanoticThe most common congenital cyanotic
heart diseaseheart disease
FeaturesFeatures
Ventricular septal defectVentricular septal defect
Obstruction to rt ventricular outflow tractObstruction to rt ventricular outflow tract
(subpulmonary stenosis)(subpulmonary stenosis)
Aorta that overrides the VSDAorta that overrides the VSD
Rt ventricular hypertrophyRt ventricular hypertrophy
35. Tetralogy of Fallot (TOF)Tetralogy of Fallot (TOF)
The most common congenital cyanoticThe most common congenital cyanotic
heart diseaseheart disease
36. FEATURESFEATURES
Ventricular septal defectVentricular septal defect
Obstruction to rt ventricularObstruction to rt ventricular
outflow tract (subpulmonaryoutflow tract (subpulmonary
stenosis)stenosis)
Aorta that overrides the VSDAorta that overrides the VSD
Rt ventricular hypertrophyRt ventricular hypertrophy
37.
38. Embryologically due to an anterosuperiorEmbryologically due to an anterosuperior
displacement of the infundibular septum indisplacement of the infundibular septum in
the truncus arteriosusthe truncus arteriosus
39. MorphologyMorphology
Boot shaped heart due to rt ventricularBoot shaped heart due to rt ventricular
hypertrophy pronounced at apexhypertrophy pronounced at apex
40. Direction of blood flow is determined byDirection of blood flow is determined by
the severity of pulmonic stenosisthe severity of pulmonic stenosis
If mild , shunt functions like a VSDIf mild , shunt functions like a VSD (pink(pink
tetralogy)tetralogy)
When pulmonic obstruction increases,When pulmonic obstruction increases,
resistance to rt outflow increasesresistance to rt outflow increases
When it reaches the level of systemicWhen it reaches the level of systemic
resistance a rt to left shunt occursresistance a rt to left shunt occurs
(cyanosis occurs) “CLASSIC TOF”(cyanosis occurs) “CLASSIC TOF”
41. TheThe tighter the subpulmonic stenosis, thetighter the subpulmonic stenosis, the
larger the aorta and the more hypoplasticlarger the aorta and the more hypoplastic
the pulmonary arteriesthe pulmonary arteries
However, the stenosis protects theHowever, the stenosis protects the
pulmonary arteries from pressure overloadpulmonary arteries from pressure overload
Rt ventricle decompresses through VSDRt ventricle decompresses through VSD
into left ventricle and aorta.into left ventricle and aorta.
Hence Rt ventricular failure rareHence Rt ventricular failure rare
Treatment : surgicalTreatment : surgical