Clinical relevance of vegetation localization by transoesophageal echocardiography in infective endocarditis

Abstract

Infective endocarditis is associated with significant morbidity and mortality, with valvular destruction and congestive heart failure being more common in patients with echocardiographically discernible vegetations. The transoesophageal approach affords consistently high quality images with excellent structural resolution. Two-hundred and eighty-one patients with clinically suspected infective endocarditis were studied, to evaluate the prognostic value of ascertaining the site of vegetations. Among them were 118 patients with vegetations attached to the aortic or mitral valve. These patients were followed for a mean period of 14 months. Mitral valve vegetations were associated with a significantly higher incidence of embolic events than vegetations on aortic valves (25% vs 9.7%). The incidence of abscess formation was higher in aortic than in mitral valve endocarditis (6% vs 0%), as were the need for surgical intervention (11% vs 5.5%) and mortality (1.6% vs 0%) respectively). Bivalvular endocarditis was associated with an increased rate of complications: embolism (50%), abscess formation (15%), surgery (35%) and mortality (10%). By multivariate analysis, echocardiographically accessible risk factors for subsequent embolism were a vegetation size of more than 10 mm and mitral valve involvement. Risk factors associated with in-hospital fatality were embolism, a vegetation size of more than 10 mm, and Staphylococcus aureus infection. Our data suggest that the site influences both the rate and the type of complications. Precise echocardiographic visualization of vegetations helps to stratify patients into a high-risk sub-group, perhaps warranting early prophylactic surgical intervention. Transoesophageal echocardiography may play an important role in assessing the clinical outcome for these patients.

Clinical Implications of Circulating Microbiome in Cardiovascular Disease Patients

“…Large vegetation in IE cases was associated with higher number of surgeries and not with increased incidence of stroke or death, more specifically; aortic valve vegetation was associated with a higher incidence of congestive heart failure and stroke [65]. Mitral valve vegetation had a significantly higher incidence of embolic events than aortic valve vegetation, while, the incidence of abscess formation was higher in aortic than in mitral valve endocarditis [66].…”

“…The implications of bacteremia in CVDs have been briefly outlined in Figure 1 and tabulated in Table 1. Large vegetation Congestive heart failure and stroke [59] Mitral and aortic valve vegetation Abscess formation [60] Bi-prosthetic valve infections Valve ring abscess and cuspal infections [62] Acute bacterial endocarditis Valve ring abscesses [63,64] and paravalvular leakage [66,67] Xenograft or mechanical valves Recurrent infections [79] Circulating endotoxemia Congestive heart failure [89,90] …”

An uncommon complication of infective endocarditis

“…3 A review involving 281 patients with suspected infective endocarditis demonstrated that the incidence of embolic events was greater with mitral than aortic valve vegetations (25% vs 10%). 4 For mitral valve vegetations, the rate of embolism was higher if these were attached to the anterior leaflet PICTORIAL MEDICINE rather than posterior leaflet. Some studies showed that the rate of embolism correlated with the size of vegetation, with the risk being higher if the diameter of the vegetation was greater than 1 cm.…”

The long and short of vegetations in infective endocarditis

“…• Timing of echocardiography with respect to onset of patient symptoms and infrequent follow-up echocardiograms to assess vegetation status; [10][11][12][13][14], while others have not [15]. The latter study was performed before the era of TEE and vegetations were visualized by TTE in only 38% of patients [15].…”

“…Vegetation length of greater than 15 mm was an independent predictor of 1-year mortality. It is unclear whether IE affecting a particular valve leads to a higher probability of embolization; mitral valve involvement has been suggested as conferring a higher embolic risk, especially with vegetations over 10 mm [12][13][14]16], while others have concluded that embolic risk is independent of vegetation location [10,11].…”