Overview and Comparison of Infectious Endocarditis and Non-infectious Endocarditis: A Review of 814 Autoptic Cases

Abstract

Aim: We examined evidence on infective and noninfective endocarditis obtained from a database of 50,403 clinical autopsies performed at an Italian general hospital between January 1983 and December 2006. Materials and Methods: Out of 814 endocarditis cases, 409 were of infective endocarditis (IE) and 405 non-infective (NIE). The median age at the time of death was 78 years for those with IE and 83 for those with NIE. Data were collected on gender, clinical history, comorbidities, kind of affected valve (nonprosthetic/mechanical/biological), pathological features of endocarditis, endocarditis complications and microbiological agents. Results: The diagnosis of IE was frequently missed and these conditions were often complicated by cardiovascular events. IE was more common among patients with prior valve infection or cardiovascular surgery, while malignancies were frequent comorbidities of NIE. Conclusion: In general, we found several data that differ from those generally present in the scientific literature, and this could be explained by the fact that data on IE and NIE are generally obtained from surgical and clinical databases, while we analysed only autoptic cases.Endocarditis is a common clinical problem characterized by lesions known as vegetations, and is defined as inflammation of the endocardium that mainly, but not exclusively, affects the heart valve leaflets. Historically, endocarditis is classified as infective (IE) and non-infective (NIE) on the basis of whether or not it is caused by infections.NIE can be caused by mechanical stress, chemical agents, immunological factors (Libman-Sacks, post-rheumatic disease, hypereosinophilic syndrome, or systemic lupus erythaematosus), or directly by turbulent blood flow that may mechanically damage the endocardium (non-bacterial thrombotic endocarditis). Moreover, it can be associated with hypercoagulable states or malignancies (nonbacterial thrombotic/marantic endocarditis).From a clinical point of view, NIE and IE have similar signs and symptoms and it is difficult to differentiate between them. Furthermore, they are associated with a consistent risk of misdiagnosis: For example, it is not rare that the hypothesis of health-care associated IE is neglected among elderly patients with multiple comorbidities because of the low specificity of usual clinical presentation (1). The diagnosis can also be completely missed, and in these cases, cardiac and extra-cardiac complications of both IE and NIE can be responsible for unexpected sudden death (2-4).These considerations help to explain why endocarditis is often diagnosed only at autopsy. However, a missed diagnosis of endocarditis is not always due to medical errors: For example, in several cases, the first clinical manifestation of NIE is a lethal stroke or severe systemic embolization, and thus the diagnosis is necessarily made only at autopsy (3).In general, pathologists have a paramount role in this field; even when endocarditis is not the cause of death, it can provide crucial information and hints to the exami...

A Transesophageal Echocardiogram Finding: From Infection to Malignancy

“…Endocarditis is an inflammation of the heart valve and endocardium, which is characterized by the formation of vegetation, and it can be bacterial or NBTE. Pre-existing valve damage was the most common predisposing factor, as the most common valvular lesions found in males were cardiac valvular dystrophic sclerocalcifications, whereas post-rheumatic valve lesions were found in females [3]. The incidence and prevalence of NBTE are unclear since the diagnosis of NBTE is most commonly made at autopsy.…”

“…Whereas another study found 405 cases out of a total of 10,874 autopsies, representing 3.7% of cases. Malignant neoplasms were found in 59%, and thrombosis was found in 38% of NBTE cases [3]. NBTE is characterized by thrombi deposition on normal heart valves without the presence of a bloodstream infection, and it typically occurs in the setting of chronic debilitating diseases such as cancer and autoimmune disorders.…”

Tricuspid valve diseases: Interventions on the forgotten heart valve

“…Endocarditis is defined as inflammation of the endocardium that typically affects the heart valves and is characterized by the formation of vegetations 9 . It is uncommon for the TV to be involved in noninfective endocarditis compared to the left‐sided valves, 9 therefore, the term TV endocarditis mainly refers to infective endocarditis (IE). Although right‐sided infective endocarditis (RSIE) only makes up 5% to 10% of IE cases, TV infective endocarditis (TVIE) makes up to 90% of RSIE cases 10 …”

441 An Atypical Case of Marantic Endocarditis in Undiagnosed Antiphospholipid Syndrome

“…It is unclear what is driving this disparity, or the clinical significance given that long term outcomes showed no gender disparity. Marantic endocarditis (ME) is difficult to differentiate from infective endocarditis (IE) [1]. We demonstrate an atypical case of ME presenting as an independently-mobile mass and severe MR. A 57-year-old man presented with a right parietal stroke secondary to mitral valve(MV) endocarditis.…”