Endocarditis

What is endocarditis?

Endocarditis is an inflammation of the inner lining of the heart (the endocardium), and is a disease which may develop suddenly (acute endocarditis) or progress more slowly. The endocardium lines not only the chambers of the heart but also the heart valves, and this is why the heart valves are particularly prone to being affected. The risk is greatest for artificial heart valves and heart valves that are already damaged, which is why valve dysfunction  places patients at an increased risk of developing endocarditis. Conversely, endocarditis can also cause permanent damage to heart valves, making it necessary for a patient to undergo valve replacement surgery.

The infectious process involved destroys the heart valves, leading to potentially severe regurgitation (leakiness) within a relatively short space of time. This results in blood clots forming near the valves, which may break off and travel to other parts of the body where they can cause stroke, pulmonary embolism or kidney damage. Endocarditis is almost always accompanied by fever and, if left untreated, is often fatal.Die Ursache ist hauptsächlich eine Infektion mit Bakterien.

Endocarditis usually develops as a result of a bacterial infection. However, the condition can sometimes be caused by certain types of cancer and certain autoimmune disorders. In Germany, the disease is now rarely seen in people with healthy hearts. The advent of antibiotics has also made this condition treatable.

What are the possible causes of endocarditis?

• Bacterial infections caused by streptococcus, staphylococcus and enterococcus or - less commonly infections caused by fungi. These may originate from other infected sites in the body, and invade the bloodstream via cuts in the skin, mucous membranes or even via a venous catheter
• Implantation of a contaminated foreign body, such as a prosthetic valve.
• Immune response: the body's response to a bacterial throat infection may lead to the production of autoantibodies, which can damage the joints and heart valves (rheumatic fever)

What are the complications that may arise?

• Permanent damage to the heart valves
• Embolization as a result of bacterial vegetation on the heart valves breaking off (stroke, pulmonary embolism, renal infarction)
• Bacterial colonization of other organs (abscesses), blood poisoning (sepsis)

Diagnosis of endocarditis

Endocarditis is a serious condition and may progress rapidly; an admission to hospital for prompt diagnosis is crucial. The diagnostic procedure for endocarditis usually includes the following steps:

• Physical examination: auscultation of the heart, examination of the skin for petechiae, enlargement of liver and spleen
• ECG for atrioventricular block (AV-block) as well as left and right bundle branch block
• Blood tests to establish levels of the markers of inflammation, such as C-reactive Protein (CRP) and procalcitonin (PCT), full blood count and renal function
• Blood cultures to test for the presence of bacteria in the blood
• Cardiac echo, both transthoracic (across outside of chest) and transesophageal (through the esophagus)

Treatment for endocarditis

As a large cardiology/cardiac surgery center, we have considerable experience in the treatment of endocarditis, a condition we encounter on a regular basis. Our Heart Center's reputation and expertise mean that many of our patients have severe endocarditis, and are referred here from other hospitals.

Our interdisciplinary approach ensures that cardiologists, cardiac surgeons and intensive care specialists/anesthetists work in close cooperation to establish the specific needs of each patient. These deliberations are followed by a consultation with the patient to determine the best possible treatment strategy. This interdisciplinary approach also allows our medical teams to respond quickly to any complications that may arise. 

• Antibiotic treatment
• Heart valve surgery

Antibiotic treatment
Treatment consists of intravenous antibiotics, specifically selected to treat the cause of the infection and administered for an appropriate length of time - usually several weeks.

A definite diagnosis of endocarditis can be established if there is clear evidence of damage to the heart valves, new vegetation on the heart valves or a positive bacterial blood culture. Sometimes it is difficult to obtain a definite diagnosis, for instance when it is too early for signs of damage to the heart valves/vegetation to have developed, or when a blood culture is negative because the patient is currently being treated with antibiotics. If there are clinical signs of endocarditis, the required treatment strategy will have to consist of blind therapy, i.e. the use of broad-spectrum antibiotics.

Heart valve surgery
If there is evidence of an increasing level of damage to heart valves, or a large amount of vegetation on the heart valves, prompt heart valve surgery or even valve replacement surgery may be required to save the patient's life. This is why it is particularly important to ensure early involvement of the cardiac surgery team in the treatment of patients with endocarditis.

Where can I find out more about endocarditis?

General information

Deutsche Herzstiftung (German Heart Foundation):
www.herzstiftung.de