Endocarditis

Classification according to ICD-10
I01.1	Acute rheumatic endocarditis
I09.1	Rheumatic diseases of the endocardium, heart valve unspecified - Chronic rheumatic endocarditis
I33	Acute and subacute endocarditis
I38	Endocarditis, heart valve unspecified
ICD-10 online (WHO version 2019)

The endocarditis (plural: endocarditis; latin endocarditis ) or endocarditis is an inflammation of the endocardium (endocardium) , the heart cavities and the heart proximal portion of the arteries and veins lining and also the structure of the heart valve leaflet forms. If left untreated, the disease is usually fatal. A distinction is made between infectious (bacterial) and non-infectious (abacterial) endocarditis. Bacterial endocarditis has become rare in Western Europe and has been treatable since the introduction of antibiotics . For some years now, the number of deaths from endocarditis as a result of the spread of nosocomial infections with multi-resistant pathogens has been increasing again. There is also an increased risk of developing endocarditis in the presence of congenital or acquired heart defects (especially after heart valve replacement ).

Dissection of an endocarditis caused by Haemophilus parainfluenzae

Morphological classification

• verrucous endocarditis
• ulcerative endocarditis
• Endocarditis polyposa / ulceropolyposa
• Endocarditis fibroplastica

Clinical classification

Abacterial endocarditis ( non- infectious endocarditis )

• Endocarditis verrucosa rheumatica or endocarditis rheumatica (cardiac involvement in rheumatic fever )
• Endocarditis thrombotica: concomitant disease with tumor diseases or also with marasmus (then called endocarditis marantica)
• Endocarditis thrombotica Libman-Sacks (organ manifestation of systemic lupus erythematosus )
• Carcinoid endocarditis
• Parietal fibroplastic endocarditis Löffler

Infectious endocarditis

• Bacterial endocarditis

- Highly acute bacterial endocarditis, also known as acute septic endocarditis and ulcerative endocarditis (pathogens: Staphylococcus aureus , Streptococcus , Enterococcus )

- subacute bacterial endocarditis = endocarditis lenta (pathogen: viridans streptococci , such as Streptococcus sanguinis (formerly called S. sanguis ), S. equinus (formerly called S. bovis ), S. mutans , S. mitis )

• Mycotic endocarditis
• Viral endocarditis (animal experiments only, see below)

causes

Endocarditis in congenital heart defects

With all heart defects in which the blood flow in the heart is not "normal", the turbulence in the blood flow in the same places over and over again can lead to the smallest injuries to the inner lining of the heart. These areas are prone to inflammation when (mostly) bacteria enter the blood and from there an infection begins, which spreads to other parts of the inner lining of the heart and one or more heart valves .

Other possibilities of infection

Bacteria can get into the blood through wounds (including invasive medical measures), injuries within the oral cavity, febrile illnesses (e.g. bronchitis , pneumonia , tonsillitis and urinary tract infections ) and, especially after heart valve replacement , form the basis for endocarditis, which in Heart-healthy people are prevented in time by the lymphoreticular system ( liver , spleen , lymph nodes , phagocytes ).

Often endocarditis in step iv -Drogenabhängigen on where then usually a highly acute bacterial endocarditis can be found.

A reduced immune defense, for example through HIV infection, promotes the occurrence of endocarditis.

At the beginning of the 21st century, nosocomial germ infection also became an increasingly serious problem with regard to endocarditis. In Germany, S. aureus is responsible for almost every second endocarditis , about 50% of the germs being acquired nosocomially and showing various multi- resistances. As a result of this development, the mortality rate for endocarditis increased again significantly, in Germany from 1105 (1990) to 1790 deaths in 2013.

Triggering germs (spectrum of pathogens)

The germs that cause endocarditis are bacteria ( Brucella melitensis , streptococci , staphylococci , enterococci , enterobacteria , gonococci , bacteria of the so-called HACEK group, etc.) and occasionally yeasts . There are no indications of the possibility of viral endocarditis apart from a few animal studies.

Endocarditis risk

The risk of infectious endocarditis is given as follows:

High risk

• artificial heart valves
• Implantation of artificial vascular connections (including transplants from human tissue)
• aorto-pulmonary shunts
• already had endocarditis
• cyanotic heart defects

Medium risk

• all congenital heart defects with malformations of large vessels (except see below)
• " Mitral valve prolapse " with leaking valve
• Operations using foreign material
• hypertrophic obstructive cardiomyopathy

Small risk

• ASD II (atrial septal defect of the second type)
• Pacemaker wearer
• Operations without the use of foreign material (suture closure of an ASD , VSD or ligation of a PDA six to twelve months after the operation)
• Mitral valve prolapse without mitral valve regurgitation (leakage of the valve)

Patients with a medium and high risk of endocarditis have usually received an endocarditis passport from their cardiologist. B. present at dental treatments.

diagnosis

• Clinical signs:
  • Unexplained fever ( intermittent fever in 90% of cases), subfebrile temperatures as an unspecific symptom
  • general symptoms: weakness or fatigue, loss of appetite, weight loss, joint pain ( arthralgia ) and muscle pain (myalgia), headache, night sweats
  • Cardiac symptoms: heart murmurs (new or changed / intensified ), signs of heart failure (water retention, liver enlargement), ECG: unspecific, block images: AV block , left bundle branch block (with myocardial abscess ), T-negativity
  • Cutaneous symptoms: petechiae (in 30% of cases), Osler nodules = painful reddish nodules the size of a lens, especially on the fingers and / or toes (= immune complex-related vasculitis), Janeway lesion: hemorrhagic lesion in the palm / sole of the foot (not painful)
  • Spleen enlargement (CAVE: septic rupture of the spleen!)
  • Kidney involvement : hematuria, proteinuria, almost regularly glomerular focal nephritis (Löhlein), microhematuria (= traces of blood in the urine )
  • Eyes: Roth's spots = Roth spots: retinal bleeding
• Laboratory:
  • Signs of inflammation ESR and CRP increased
  • Anemia ( anemia ) in 80% of cases
  • Detection of bacteria in blood cultures (although bacterial pathogens may have caused endocarditis even if the culture was negative)
• Sonography :
  • Possibly. vegetations (= "growths and deposits" that the body forms at the inflamed area in the heart as a "repair process") are visible.

Complications

• Destruction of heart valves
• Vegetations (see above) are torn loose by the pumping heart and clog blood vessels in the organs as they flow through the bloodstream . The dreaded complications from this can be: a stroke , a kidney embolism or a pulmonary embolism , whereby the stroke is particularly feared, as it carries a high risk of inflammation of the brain or meninges.
• Spreading of germs to other organs, where abscesses can then form.

In the course of blood poisoning ( sepsis ) and septic or toxic shock with poisonous bacteria, acute organ failure can occur (kidney failure, so-called shock kidney and / or lung failure, so-called shock lung).

Signs of clinical complications

• increasing exertional dyspnea / orthopnea
• Signs of central embolization of vegetation material
  • Impairment of consciousness, circumscribed neurological deficits
• Signs of peripheral embolism
• immunological phenomena (e.g. Osler nodules )

Diagnosis of infectious endocarditis

The (modified) Duke criteria play a central role in the diagnosis of endocarditis . For the diagnosis of endocarditis, echocardiography , blood cultures for bacteriological examinations, tissue examinations and clinical examinations are available, in some cases with other imaging methods. The detection of changes in the heart valves or new vegetation in the heart or the detection of germs in the blood culture are sure signs. Both types of evidence are sometimes difficult to provide because, despite the presence of endocarditis, no valve changes / vegetation have yet formed or the detection of germs in the blood culture is not possible because the patient has already received antibiotics .

Therapy of infectious endocarditis

Succeeds, the detection of bacteria in the blood culture is not (5 to 10% of cases) or it is not yet known, it must at the acute infection and the presence of clinical signs calculated ( "blind") to be treated. When choosing antibiotics, the different spectrum of pathogens in the presence of natural heart valves (native valves) and valve prostheses are taken into account. A broadly effective intravenous antibiotic therapy is carried out clinically with initially strict bed rest over a period of four to six weeks, with at least the first two weeks of therapy taking place under inpatient control. This is followed by a one to two week critical observation. In the case of a subacute course , the microbiological test results can be waited for and then treated with antibiotics.

Endocarditis, once through, increases the risk of developing another disease. This is why prophylaxis (see below) is of particular importance.

In the case of active endocarditis, surgical therapy can also be considered, for example in the case of life-threatening heart valve insufficiencies, abscesses or larger or spreading vegetations in the area of ​​heart valves, pathogens that are difficult to treat or, despite therapy, persistent fever or bacterial count in the blood, sepsis and septic shock, acute embolism in the brain and endocarditis due to infection of a joint prosthesis.

prophylaxis

Endocarditis prophylaxis

In the case of planned interventions ( dentistry , endoscopy , surgery , see above ), prophylaxis should be considered in patients with an increased risk of endocarditis , which consists of, for example, the administration of an antibiotic about an hour before the treatment and, if necessary, a second administration a few hours afterwards. Good oral hygiene is generally beneficial; it constantly reduces the number of germs and not only during visits to the dentist.

New guidelines for the prophylaxis of bacterial endocarditis, including a comprehensive discussion of how it could develop, were published in 2007 by the American Heart Association (AHA). The AHA assessed the risk of an endocarditis infection much more cautiously than before and considered the prophylaxis practiced to date to be dispensable in the majority of cases. In its 2009 guidelines, the European Society for Cardiology also restricted the prophylactic administration of antibiotics to high-risk patients.

Endocarditis prophylaxis is currently necessary in the following patients with a high risk of endocarditis:

• Heart valve replacement patients
• Patients with heart transplants and developing heart valve disease
• Patients with certain congenital heart defects
• Patients who have had endocarditis
• Patients with reconstructed heart valves made from foreign material (max. Six months after surgery)

Endocarditis prophylaxis is carried out with antibiotics such as amoxicillin (or ampicillin ), in the case of penicillin allergy with clindamycin (alternatively cefalexin or clarithromycin ), cefazolin or ceftriaxone .

Treatment of febrile illness

For all diseases that are triggered by a bacterial infection (see above), treatment with an antibiotic is necessary for a sufficiently long time to prevent the development of endocarditis in addition to or as a consequence of the underlying disease. Even with a primarily viral infection (against which an antibiotic is not effective), antibiotics can be useful to avoid bacterial superinfection .

literature

• Marianne Abele-Horn: Antimicrobial Therapy. Decision support for the treatment and prophylaxis of infectious diseases. With the collaboration of Werner Heinz, Hartwig Klinker, Johann Schurz and August Stich, 2nd, revised and expanded edition. Peter Wiehl, Marburg 2009, ISBN 978-3-927219-14-4 , pp. 13–35 and 309–311.
• European Society of Cardiology (ESC): Guidelines on prevention, diagnosis and treatment of infective endocarditis. In: European Heart Journal. Volume 30, 2009. pp. 2369-2413.
• Infectious Diseases Society of America (IDSA): Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications. In: Circulation. Volume 111, 2005, pp. E394 – e433.
• Christoph K. Naber: S2 guideline for diagnosis and treatment of infectious endocarditis. In: Journal of Cardiology. Volume 93, 2004, pp. 1004-1021.
• N. Westphal, B. duty, Christoph Naber: Endocarditis prophylaxis, diagnostics and therapy. In: Deutsches Ärzteblatt. Volume 106, 2009, pp. 481-490. Online: Abstract
• Herbert Reindell , Helmut Klepzig: diseases of the heart and blood vessels. In: Ludwig Heilmeyer (ed.): Textbook of internal medicine. Springer-Verlag, Berlin / Göttingen / Heidelberg 1955; 2nd edition ibid. 1961, pp. 450-598, here: pp. 516-522 ( Die Endokarditis ).

Web links

Wiktionary: Endocarditis  - explanations of meanings, word origins, synonyms, translations

• Position paper on the prophylaxis of bacterial endocarditis of the German Society for Cardiology, November 2007 (PDF file; 578 kB)
• Prevention of Infective Endocarditis. Guidelines From the American Heart Association, 2007 (revised 20070419)

Individual evidence

1. ↑ cardiovasic , February 2015, pp. 23-24.
2. ↑ Medical microbiology and infectious diseases, edited by Sebastian Suerbaum, Helmut Hahn, Gerd-Dieter Burchard, Stefan HE Kaufmann, Thomas F. Schulz, Springer-Verlag, 2012, p. 309 [1]
3. ↑ W. Hort (ed.), Pathology of the endocardium, the coronary arteries and the myocardium, Springer 2000]
4. ^ D. Kühn, J. Luxem, Klaus Runggaldier: Rescue Service (3rd edition) . Urban & Fischer Verlag, Munich 2004, ISBN 3-437-46191-5 .
5. ↑ Prevention of Infective endocarditis. Guidelines From the American Heart Association, 2007 ( Memento of the original dated March 2, 2008 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. 
6. ↑ [2] (PDF; 869 kB) Endocarditis prophylaxis according to the new guidelines of the European Cardiological Society, Journal of Cardiology 2011, accessed June 19, 2011.
7. ↑ [3] Endocarditis prophylaxis according to Deutscher Herzstiftung e. V.
8. ↑ Marianne Abele-Horn (2009), p. 311.

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