The defeat of the tricuspid valve with infective endocarditis. Hidden danger: infectious bacterial endocarditis

Infective endocarditis is a serious disease in which the inner membranes of the heart chambers (endocardium), valves, tendon chords are affected. In places where the infection is localized, an amorphous mass is formed, consisting of platelets and fibrin, which contains many microorganisms and a moderate amount of inflammatory bacteria. Bacterial endocarditis of deep structures in the heart is distinguished by a complex diagnosis and a rapid course, which in more than 50% of cases is fatal.

Causative agents of infective endocarditis

An infection of any origin can cause IE. With infectious endocarditis, the clinical picture is dominated by bacteria of the genus Staphylococcus, mainly coagulase-negative species: epidermidis, saprophyticus, haemolyticus, hominis. Further, along the descending line, go:

• hemolytic streptococci species;
• group D streptococcus - enterococcus,
• gram-negative bacteria;
• a group of causative agents NASEK (hemophilic bacillus, actinobacteria, cardiobacteria, eikenella, kingella).

According to the WHO medical statistics, NASEC is the causative agent of IE in 4–8% of cases. It should be noted that even with a careful search for the form and type of provocateur, in 3-10% of patients the results of blood cultures are negative.

Features of individual pathogens:

1. Greening streptococci. They are permanent inhabitants of the nasopharynx, they are activated in favorable conditions. For example, when the general body temperature rises. They are extremely sensitive to penicillin, therefore, an effective combination of penicillin and gentamicin is used to destroy green streptococci.
2. Streptococcus bovis. Live in the digestive tract, causes infective endocarditis in 20-40% of diagnosed cases of heart disease. It often accompanies polyps and malignant formations in the rectum, therefore, a colonoscopy is prescribed to determine the type of pathogen, if other tests are negative. They are divided into four groups - A, B, C and G. More often than others, they cause primary disease of healthy heart valves.
3. Streptococcus pneumoniae. Pneumococcal bacteria are common. Under its negative influence, the destruction of healthy tissues in the heart occurs, causing extensive and multiple myocardial abscesses. Difficult to diagnose. The clinical picture of complications and prognosis is unfavorable.
4. Enterococci. They are part of the normal flora of the gastrointestinal tract and cause diseases of the genitourinary tract, are responsible for 5-15% of cases of IE. The disease has the same frequency in older men and women (often the entrance gate is the urinary tract) and in 15% of cases is associated with nosocomial infection. Enterococci infect normal, abnormal, and artificial valves in the heart. The onset of the disease is acute or subacute. The mortality rate is comparable to that in IE caused by streptococcus greens.
5. Staphylococci. Coagulase-positive staphylococci are represented by a single species - S. aureus. Of the 13 species of coagulase-negative staphylococci that colonize humans, S. aureus has become an important pathogen under the conditions of implanted devices and iatrogenic infection. This microorganism is the main cause of infective endocarditis. IE caused by S. aureus is a highly toxic febrile disease that affects the heart and in 30–50% of cases occurs with complications from the central nervous system. Cerebrospinal fluid usually shows neutrophilic leukocytosis with a positive culture test for S. aureus.
6. Coagulase-negative staphylococci. Microorganisms, especially epidermidis, are the main cause of EI, especially during the first year after surgery on any valve in the heart, and an important cause of nosocomial IE. Endocarditis, caused by coagulase-negative staphylococcus aureus, is often accompanied by complications and is fatal. Community-acquired S. lugdunensis species are associated with valve damage in the heart and the need for surgery.
7. Gram-negative bacteria. They are part of the flora of the upper respiratory tract and oropharynx, infect altered heart valves, causing a subacute form of the disease, and are the cause of pathology that occurs within a year after surgical intervention on the valve. They have special requirements for the nutrient medium and grow slowly; they are usually found in the blood after 5 days of incubation. The relationship between bacteria and massive vegetation and a high frequency of systemic embolism has been established.

P. aeruginosa is a gram-negative bacillus that causes endocarditis. Enterobacteriaceae become the causative agents of bacterial endocarditis only in some cases. Mortality from IE caused by gram-negative bacilli, frequent - 50%;

Neisseria gonorrhoeae is a rare cause of endocarditis today. The microorganism infects AK in young patients, causes its destruction and intracardiac abscesses. N. gonorrhoeae is usually susceptible to ceftriaxone, but there is now widespread resistance of N. gonorrhoeae to antibiotics, therefore, for adequate therapy, the sensitivity of the isolated microbe should be determined

8.Other microorganisms. Corynebacterium spp. Strains called diphtheroids often contaminate the blood. These organisms are the most important cause of IE, and unexpectedly often cause endocarditis of altered, abnormal valves in the heart.

9. Mushrooms. Candida albicans, non-white Candida species, Histoplasma spp. and Aspergillus spp. - the most pathogenic fungi identified as the cause of IE. Unusual, new types of fungi and mold are responsible for at least 15% of cases of endocarditis in the heart.

The summary table shows the frequency of cases of the disease from viral pathogens:

Classification and types

The unified international classification of infective endocarditis is used by cardiologists around the world to isolate various types of disease in order to accurately collect symptoms and diagnose. Designed back in 1975, it undergoes improvements every year. Infective endocarditis, according to the modern version, is usually subdivided as follows:

1. Etiology - what caused the clinic of the disease (streptococcus, staphylococcus, enterococcus, etc.).
2. What valves in the heart are affected (for example, endocarditis of the aortic, mitral valve).
3. Primary - arising on a healthy valve in the heart. Secondary, which develops on a previously modified valve.
4. The course of the disease is acute (up to 2 months from the onset of clinical manifestations) and subacute (more than 2 months from the beginning of the clinic).
5. Specific forms of infective endocarditis:

• prosthetic heart valves;
• drug addicts;
• nosocomial (nosocomial form);
• in the elderly;
• in persons on systemic hemodialysis.

It should be noted that these categories of patients constitute the highest risk group. In developed countries, 10–20% of IE cases are attributed to prosthetic valve endocarditis. The number of patients of middle and old age is also growing, as evidenced by the fact that the average age of patients is 50-60 years.

Types of endocarditis by classification

Primary infective endocarditis

The number of cases of this form of pathology has increased significantly and is currently about 50%. The following set of characteristic symptoms becomes the signs of primary IE:

1. Most of the patients are over the age of 40.
2. Acute onset, often under the "mask" of other diseases developing in the heart and other organs.
3. High resistance of the disease to the therapy, associated with the late start of treatment and the presence of powerful defense mechanisms in bacteria against antimicrobial agents.
4. Valves in the heart are affected.
5. High mortality, which in this form of IE is from 50 to 91%.

In the initial stages of the disease, cardiac manifestations of the clinic are rare. Heart murmurs in most patients during the initial visit to the doctor are not determined, as a result, the disease is usually diagnosed late, in 30% of cases - after the formation of a heart defect. The main causes of death in primary endocarditis are progressive circulatory failure (90%) and thromboembolism (9.5%).

Secondary infective endocarditis

There are the following variants of the disease of this form:

• IE on the background of rheumatic heart disease. At present, the proportion of this variant of IE has slightly decreased, due to an increase in the incidence of the primary form of the disease and is 36-40%. Secondary IE of rheumatic valves is localized more often on the mitral valve in the heart. The most typical subacute onset;
• IE on the background of congenital heart defects. It makes an average of 9% of all admitted with a diagnosis. Congenital malformations are complicated by the development of IE in 5–26% of cases, usually between the ages of 16 and 32, and only in 2.6% of cases IE develops over the age of 40. Symptoms in this form of IE are variable, but more often it is characterized by a mild, blurred clinical picture, and prolonged remissions. Patent ductus arteriosus is complicated by IE in 20–50%, ventricular septal defect - in 20–40%, Fallot's tetrad, pulmonary artery stenosis, coarctation of the aorta in the heart - in 10–25% of cases, bicuspid aortic valve - in 13%;
• bacterial endocarditis against the background of atherosclerotic cardiosclerosis and sclerotic lesions of the aorta. The frequency of this form in recent years has increased significantly and in the general structure of IE is 5-7%. Typical for this variant of IE are advanced age of patients and an atypical clinical picture, often occurring at the onset of the disease under the guise of characteristic diseases. The infectious process causes a rapidly progressive course;
• bacterial endocarditis, as a complication of heart surgery;
• endocarditis with artificial valves in the heart develops in 1.5–8% of cases. Surgical intervention against the background of disease progress - 7–21%. The development of endocarditis within 60 days after implantation in the heart is regarded as early IE and has an extremely high mortality rate of up to 75%. With late IE, mortality is 25%. Such high mortality rates are associated with profound immunodeficiency in this category of patients;
• bacterial endocarditis after commissurotomy of the aortic and mitral valves in the heart occurs in 3–10% of cases, usually 5–8 months after surgery. The prognosis for this form of endocarditis is unfavorable.

Stages

Stage I - initial

It is characterized by macroscopic thickening and edema of the valves and histological-mucoid swelling of the heart endocardial substance, mild lymphocellular infiltration with fibroblast proliferation, and moderate focal sclerosis. At this stage, the prognosis of treatment is most favorable (70% survival rate).

Stage II - warty

The appearance of warts along the line of closure of the valves and / or on the parietal endocardium in the heart. Depending on when they form, valve warts can be tender, loose, or hard. Histologically, with infectious endocarditis at this stage, changes in the connective tissue of the fibrous type, edema and dissociation of the structures of the heart, vascular hemorrhages, myocarditis are determined.

Stage III - warty-polyposis

Ulcers form and bacteria become fixed on the valves. Macroscopically, on the parietal endocardium and valves, polypous-warty formations are determined, with a characteristic histological picture of a septic form of endocarditis. The presence of ulcers and pyogenic bacteria on tissues in the heart. Valves are affected multiple times, up to complete melting. The lesion is not strictly localized. The pathological process involves all the membranes of the heart (pericardium, myocardium, endocardium), as well as vessels, fibrous rings of valves, papillary muscles. In the myocardium, pronounced edema, lymphocellular infiltration, fatty and protein degeneration, expansion of sinusoidal vessels with stasis can be noted. Old and fresh areas of disorganization of the connective tissue of the heart are observed. The stage is characterized by the continuity of the morphological process. Comparison of changes in valves and parietal endocardium shows that these metamorphoses can be considered as successive links of the same process, inflammatory destruction of connective tissue in the heart.

Rheumatic endocarditis

Rheumatic endocarditis stands out in the classification of infectious (or bacterial) endocarditis and is a complication of joint diseases. It occurs against the background of inflammatory processes in the synovial bags of the joints. It is characterized by damage to the mitral, aortic valve, tendon chords and parietal endocardium in the heart. The classification of rheumatic endocarditis is based on the nature and form of damage to the tissue structure in the heart.

Rheumatic endocarditis is of several types:

Diffuse form characterized by diffuse damage to the entire valve apparatus. Thickening of the leaflets and the appearance of granulomas leads to a violation of hemodynamics. Early treatment can prevent complications. Otherwise, the diffuse form progresses to extensive granulomatosis, which leads to a shortening of the valves and the formation of rheumatic heart disease.

Acute warty rheumatic endocarditis the heart is characterized by the deposition of platelets and fibrin in the affected areas, resulting in the formation of many warts. If an infectious agent enters the heart cavity, there is a risk of infective endocarditis. Anti-inflammatory therapy of the disease prevents the development of serious disorders in the work of the heart.

Recurrent verrucous endocarditis differs from the acute form in the course of the disease. The pathology is characterized by the periodic appearance of warts on the valves of the heart during exacerbations. Radiography and echocardiography of the heart are used to confirm the diagnosis.

Fibroplastic form of rheumatic endocarditis represents a critical stage. With this course of the disease, irreversible changes are formed in the heart valve system, which are treated only with the help of surgery, the probability of survival in this form is not more than 20%.

Acute and subacute infective endocarditis

From a clinical point of view, the most important is the division of infective endocarditis into acute and subacute. It is carried out, first of all, not according to the principle of the limited process in time (less than 2 months, more than 2 months), but by the severity, form of the disease, speed, frequency of development of complications and therapeutic prognosis.

Acute infective endocarditis

Acute infective endocarditis (AIE) is clinically sepsis with primary localization of infection on the valve apparatus of the heart. The features of the EIE include:

• pronounced infectious toxic syndrome (often with the development of infectious toxic shock);
• rapid destruction of heart valves with the formation of defects and heart failure, sometimes developing in 1-2 weeks and requiring immediate surgical correction;
• high incidence of thromboembolic complications in the heart;
• frequent formation of purulent metastases in various organs and tissues;
• high mortality.

AIE in the heart is often primary, caused by Staphylococcus aureus. With infective endocarditis in drug addicts and in the early stage of prosthetic endocarditis, the course of the disease is acute. Splenomegaly is a sign of OIE and is detected in 85-98% of deceased persons. Spleen infarctions and abscesses are found in 23.6 and 10.5% of cases, respectively. Septic pneumonia is observed in 21-43% of patients with AIE with damage to the left heart chambers and in 66.7% of patients with AIE with damage to the right heart chambers.

Kidney damage - the clinic is manifested by acute nephritis with moderate urinary syndrome. Quite often, renal infarctions develop (30-60%) as a result of renal artery embolism. With infective endocarditis, toxic hepatitis often develops (30-40%). DIC syndrome with the formation of acute ulcers in the stomach, duodenal bulb, gastrointestinal bleeding occurs in 45.8% of cases. Immunological complications of endocarditis are rare, due to the fulminant course of the disease.

Subacute infective endocarditis

Subacute infective endocarditis (PIE) is a valve infection in the heart. With PIE, the clinic of sepsis is rarely observed, the frequent development of immunological complications is characteristic:

• jade;
• vasculitis;
• synovitis;
• polyserosite.

This variant of the disease occurs with a low-virulent pathogen (streptococcus, epidermal staphylococcus). Bacterial or rheumatic endocarditis, as a rule, develops in patients with previous cardiac pathology and is characterized by a more favorable prognosis.

With subacute IE, the clinical picture unfolds gradually, within 2-6 weeks and differs in the variety and severity of the main symptoms. The most common manifestations of immune damage are vasculitis, arthralgia (arthritis), myalgia, glomerulonephritis, myocarditis. Vasculitis of peripheral vessels is manifested by petechiae, Osler's nodules (microvascular septic emboli), Roth's spots (retinal hemorrhages detected by examination of the fundus) and Geneway (hemorrhagic spots from 1 to 4 mm on the palms and feet). With PIE, the musculoskeletal system is quite often affected, a decrease in body weight is characteristic.

Prolonged subacute course of infective endocarditis

The clinical picture is very diverse and consists of symptoms of infectious-septic intoxication, heart failure, clinical syndromes associated with damage to visceral organs. Among them, the leading is the defeat of the heart and blood vessels. However, a detailed clinic of the subacute course of IE is not observed immediately, and the initial set of symptoms is diverse.

According to the leading clinical syndrome, various options are distinguished:

• renal;
• thromboembolic;
• anemic;
• coronary;
• splenomegalic;
• hepatosplenomegalic;
• cerebral;
• polyarthric;
• feverish.

The clinical course of IE and the prognosis of the disease are largely determined by the activity of the pathological process. Distinguish between low, moderate and the highest degree of activity of infective endocarditis.

Clinical manifestations of endocarditis in the table (frequency of cases in%):

Bacterial endocarditis symptoms

Bacterial endocarditis is not always symptomatic. In some cases, the disease can develop suddenly, bypassing even the passage of stages. Symptoms are often secondary and do not indicate heart problems. Everything can start quite prosaically. It begins with a runny nose, sometimes sinusitis develops, as is the case with other diseases. A person is not up to treatment. Often it ends in tears, the patient can cause irreparable damage to his heart. Not attaching importance to the symptoms that accompany any infectious disease, the patient carelessly misses the onset of complications of a simple disease, one of which is bacterial endocarditis.

Treatment must necessarily be comprehensive for any symptoms of colds:

• nausea, vomiting;
• fever, delusional state;
• a sharp rise in temperature for no apparent reason;
• shortness of breath, feeling short of breath;
• dry cough, paroxysmal;
• pain, aching joints;
• sleep disturbance, anxiety, weakness;
• chills followed by unbearable stuffiness.

For example, tonsillitis. It is, accordingly, caused by some infectious pathogens. If left untreated, they begin to spread throughout the body, can enter the heart and remain on the valves, causing inflammation and damage to tissues and structural elements.

The absolute diagnosis of bacterial endocarditis is the confirmation of at least two out of three bacterial cultures on the pathogen. Blood is taken under sterile conditions (from different veins) and if in two out of three cases the growth of the same pathogen is confirmed, the diagnosis is highly probable in the presence of the so-called complex of minor symptoms.

Small symptoms include punctate eruptions characteristic of bacterial endocarditis. They appear at the nail bed, on the oral mucosa and on the conjunctiva. The most important diagnostic method is ultrasound confirmation of lesions of the aortic, mitral valve in the heart. If the disease is recognized as infectious, antibiotic therapy should be complete and last exactly as long as the doctor prescribes. Three or five days of taking antibiotics, determined independently or on the recommendation of a neighbor, will not lead to anything good.

First of all, for bacterial endocarditis, the characteristic feature is the defeat of the aortic valve. The aortic valve and its valves, to which vegetation is attached, cannot hold a large mass for a long time. And the particles break away from the hearts, they are carried away by the bloodstream. These are the so-called septic metastases that spread throughout the body. The second source of the disease is the mitral valve, where decaying vegetation also breaks off and is carried away by the systemic circulation. In right-sided bacterial endocarditis, they attach to the tricuspid valve and are carried away into the pulmonary artery, causing a lung abscess.

Treatment for infective endocarditis is aimed at removing the infection not only from the heart, but also from the blood. Relapses of endocarditis often occur within one month of therapy. If symptoms recur 6 weeks after the end of treatment, this is not a relapse, but a new infection. A blood test must be taken in the morning and on an empty stomach. Bacterial endocarditis, if left untreated, leads to destruction of the heart valves and heart failure.

Diagnostics

Infective endocarditis presupposes complex diagnostic measures, due to a blurred picture of symptoms that are characteristic of very many diseases and a wide range of provocative microorganisms. Without this, the appointment of adequate treatment is impossible.

Taking anamnesis

The first symptoms of infective endocarditis begin to appear 2 weeks after the incubation of the pathogenic agent. Any abnormal manifestations become clinical signs - from erased symptoms to acute heart failure against a background of severe valvular insufficiency with rapid destruction of the leaflets. The onset can be acute (Staphylococcus aureus) or gradual (Streptococcus greens).

Physical examination

In the typical course of infective endocarditis, a general examination is carried out, which makes it possible to identify numerous non-specific symptoms:

• pallor of the skin with a grayish-yellow tint. The pallor of the skin is explained by the anemia characteristic of infective endocarditis, and the icteric skin tone becomes a sign that the liver is involved in the pathological process;
• weight loss is a symptom typical of patients with infective endocarditis. Sometimes it develops very quickly, more often within a few weeks minus 15-20 kg;
• changes in the terminal phalanges of the fingers in the form of "drumsticks" and nails like "watch glasses", which are detected during a relatively long course of the disease (about 2-3 months);
• peripheral symptoms due to vasculitis or embolism. Painful petechial hemorrhagic rashes appear on the skin; they are small in size, do not fade when pressed, and are painless on palpation. Often, petechiae are localized on the front upper surface of the chest (where the heart is), on the legs, eventually acquire a brown tint and disappear. Sometimes hemorrhages are localized on the transitional fold of the conjunctiva of the lower eyelid (Lukin's spots) or on the mucous membranes of the oral cavity. Roth's spots are similar to Lukin's spots - small hemorrhages in the retina, in the center also having a blanching zone, which are detected during a special diagnosis of the fundus;
• linear hemorrhages under the nails. Osler's nodules are painful, reddish, tense formations the size of a pea, located in the skin and subcutaneous tissue on the palms, fingers, and soles. But it is worth mentioning that the peripheral symptoms of infective endocarditis are rarely detected during diagnosis.

Other external manifestations of the disease

The symptoms of endocarditis are caused by immune damage to internal organs, thromboembolism, and the development of septic foci. Neurological symptoms that are signs of cerebral complications (cerebral infarction resulting from thromboembolism of cerebral vessels, intracerebral hematomas, brain abscess, meningitis and other diseases). Signs of pulmonary embolism (PE), often revealed during diagnosis in case of damage to the tricuspid valve (especially often in drug addicts) - shortness of breath, suffocation, chest pain, cyanosis.

Palpation and percussion of the heart

It is recommended to perform palpation and percussion of the heart, which will allow diagnosing the localization of an infectious lesion (aortic, mitral, tricuspid valve). And also the presence of a concomitant disease, in the heart or another, against which infective endocarditis has developed. In most cases, there are signs of LV dilatation and its hypertrophy: displacement of the apical impulse to the left and the left border of the relative dullness of the heart, diffuse and increased apical impulse.

Heart auscultation

Laboratory diagnostics

In laboratory diagnostics of the disease, a general blood test reveals leukocytosis, normochromic anemia, and an increased erythrocyte sedimentation rate. Rheumatoid factor is elevated in 50% of patients. Positive C-reactive protein and hypergammaglobulinemia are noted. In the general analysis of urine - microhematuria with or without proteinuria. In the biochemical diagnosis of blood, hypoalbuminemia, azotemia and an increase in creatinine levels are detected. In the coagulogram, the prothrombin time may be slightly increased, the Quick index of prothrombin decreased, and the level of fibrinogen increased.

Instrumental diagnostics

Imaging is recommended, in particular echocardiography, which plays a key role in the diagnosis and management of a patient with IE. Echocardiography is also useful for assessing the prognosis of patients with endocarditis, treatment dynamics, and after surgery.

Transesophageal echocardiography (TEE) is also recommended and plays an important role before and during surgery (intraoperative echocardiography). But the assessment of patients with any stage of IE disease is no longer limited by conventional echocardiography. It should include MSCT, MRI, positron emission tomography (PET) or other functional diagnostic methods.

Other diagnostics

X-ray can reveal the expansion of the boundaries of the shadow in the heart. With a pulmonary infarction, thin wedge-shaped shadows are found in the middle or lower field, often on the right. In dynamics, the changes disappear after 7-10 days, but hypostatic pneumonia and hemorrhagic pleurisy can join. With left ventricular failure, a picture of pulmonary edema can be detected.

Computed tomography (contrast), magnetic resonance imaging (vascular program) or angiography of cerebral vessels should be performed in all patients with active infective endocarditis of the left chambers of the heart, as well as in patients in remission with a history of neurological complications associated with infective endocarditis (thromboembolism in cerebral vessels, hemorrhagic stroke, persistent headaches) in order to diagnose mycotic aneurysms in the heart and other organs. Mycotic cerebral aneurysms occur in about 2% of patients with infective endocarditis. Aneurysm ruptures lead to death.

Surgical treatment of aneurysms in the setting of severe heart failure is associated with a high risk, but surgical treatment of heart defects can increase the likelihood of intracerebral hemorrhage due to heparinization during extracorporeal circulation. Timely diagnosis of aneurysms allows you to determine the tactics of surgical treatment. Computed tomography of the chest organs (including with pole contrasting) is shown to patients to clarify the picture of lung damage, localization and spread of abscesses, false aortic aneurysms in case of infective endocarditis of the aortic valve.

What outcome is possible in children

In accordance with the recommendations developed by the Committee of Experts of the American Heart Association (1997), antibiotic prophylaxis is indicated to the greatest extent for such children and adolescents in whom IE not only develops significantly more often compared to population data (moderate risk), but is also associated with high mortality ( high risk).

Below are the risk groups for IE.

High risk group:

• artificial heart valves (including bioprostheses and allografts);
• IE in history;
• complex "blue" congenital heart defects (tetralogy of Fallot, transposition of large arteries, etc.);
• operated systemic pulmonary shunts.

Moderate risk group:

• non-operated congenital heart defects - patent ductus arteriosus, VSD, primary ASD, coarctation of the aorta, bicuspid aortic valve;
• acquired heart defects;
• hypertrophic cardiomyopathy;
• MVP with mitral regurgitation and / or thickening of the leaflets in the heart.

Low risk group:

• isolated secondary ASD;
• operated congenital heart defects - ASD, VSD, patent ductus arteriosus;
• history of coronary artery bypass grafting;
• mitral valve prolapse without mitral regurgitation;
• functional or "innocent" heart murmurs;
• a history of Kawasaki disease without valvular dysfunction;
• a history of rheumatic fever without a heart defect.

Diseases of the MVP form are often found in children and adolescents, and are not always a reflection of any structural or functional valvular disorders. In the absence of structural changes in the valve leaflets, systolic murmur and echocardiography - symptoms of mitral regurgitation (or with a minimal degree of its severity), the risk of IE in children and adolescents with MVP does not differ from the population risk. Antibiotic prophylaxis of the disease in these cases is inappropriate. If MVP is accompanied by moderate (even more pronounced) mitral regurgitation, the latter contributes to the emergence of turbulent blood currents, and thus increases the likelihood of bacterial adhesion to the valve during bacteremia. Therefore, antibiotic prophylaxis is indicated for such children and adolescents. MVP can be a consequence of myxomatous valvular change, accompanied by thickening of the leaflets, while the development of regurgitation is possible during exercise. Such children and adolescents are also at the average risk of developing IE.

Antibiotic prophylaxis of endocarditis is indicated for all children and adolescents who fall into the high or moderate risk category when performing various dental procedures, surgical interventions and instrumental diagnostic procedures that may be accompanied by transient bacteremia: tooth extraction, periodontal manipulations, interventions on the root of the tooth, adenotomy, tonsillectomy, biopsies of the mucous membranes of the respiratory tract and gastrointestinal tract, cystoscopy, etc. Along with this, it is extremely important to educate children, adolescents and parents about the need for careful hygienic oral care and timely access to a doctor for any intercurrent bacterial infection.

The prognosis is determined by the type of microbe-provocateur, background cardiac pathology, the nature of the process, the presence of complications, the timeliness and adequacy of treatment. Full recovery is possible with a favorable long-term prognosis in the absence of embolism, signs of heart and renal failure. Despite the achievements of modern clinical medicine, mortality among children and adolescents remains high - about 20%.

Complications

Heart failure

When the valves in the heart are affected, they are deficient. Myocardial dysfunction arising against the background of a negative process, in turn, causes myocarditis or heart attack. All structures of the heart are involved in the process. Embolism in the coronary arteries, possible overlapping of the orifice of the coronary artery by a fragment of vegetation or a destroyed aortic valve leaflet ultimately lead to heart failure. In this case, conservative therapy is prescribed, which takes into account infective endocarditis in the treatment regimen. All medical measures are not specific and are carried out in accordance with the recommendations of the Ministry of Health for the treatment of chronic heart failure.

Neurological complications

Neurological complications develop in more than 40% of patients diagnosed with infectious (rheumatic) endocarditis. This happens as a result of embolism by fragments of vegetation. Clinical manifestations are broad and include:

• ischemic and hemorrhagic stroke;
• latent cerebral embolism;
• brain abscess;
• meningitis;
• toxic encephalopathy;
• apoplectic stroke;
• symptomatic or asymptomatic infectious aneurysm.

Infectious aneurysms

Infectious (fungal) aneurysms of various localization are formed as a result of septic embolism of the vasa-vasorum or the direct penetration of infection into the vascular wall. The clinical signs of an infectious aneurysm are varied (focal neurological symptoms, headache, hemorrhagic stroke), therefore angiography should be performed to determine intracranial AI in any case of IE with neurological symptoms. Computed tomography (CT) and magnetic resonance imaging (MRI) with high sensitivity and specificity make it possible to diagnose IA, but angiography remains the gold standard in the diagnosis of IA and should be used in all cases when there is doubt about the results obtained.

Ruptured aneurysms have a poor prognosis. In cases with large, dilated, or ruptured infectious aneurysms, neurosurgical or endovascular treatment is recommended. After a neurological complication, most patients with infective endocarditis still have at least one of the indications for surgery. The risk of postoperative deterioration in neurological status is low after latent cerebral embolism or transient ischemic attack. After ischemic stroke, heart surgery is not a contraindication. The optimal time interval between stroke and surgery is controversial due to insufficient research.

If cerebral bleeding is ruled out by CT and the neurological deficit is not too pronounced, it is recommended not to postpone surgical treatment. Of course, if there are indications for it (heart failure, uncontrolled infection, repeated embolism). The operation has a relatively low level of neurological risk (3-6%). In cases of intracranial bleeding, the neurological prognosis is worse and surgery should be postponed for at least one month. If heart surgery is urgently needed, close cooperation with the neurological team is necessary.

Acute renal failure (ARF)

A common complication of infective endocarditis, which is diagnosed in 30% of patients with a confirmed diagnosis. It is extremely unfavorable in terms of the forecast.

Arrester reasons:

• glomerulonephritis;
• hemodynamic disturbances in cases of heart failure, severe sepsis, after surgery on the heart;
• the toxic effect of antimicrobial therapy, most often caused by aminoglycosides, vancomycin and high doses of penicillin;
• nephrotoxicity of contrast agents used for radiography.

Some patients may require hemodialysis, but acute renal failure is often reversible. To prevent ARF, antibiotic doses should be adjusted according to creatinine clearance with careful monitoring of serum concentrations (aminoglycosides and vancomycin). Radiography with nephrotoxic contrast media should be avoided in people with poor hemodynamics or pre-existing renal impairment.

Rheumatic complications

Bone muscle symptoms (joint pain, myalgia, back pain) are common with infective endocarditis and may be the first manifestations of the disease. Peripheral arthritis occurs in 14%, and spondylosis occurs in 3-15% of cases. A CT or MRI of the spine should be performed on patients with endocarditis experiencing back pain. Conversely, echocardiography should be performed in individuals with an established diagnosis of pyogenic spondylosis and risk factors for infective endocarditis.

Spleen abscess

Despite the prevalence of splenic embolism, abscess is a rather rare complication of IE. It should be ruled out in patients with persistent fever and bacteremia. Diagnostic methods: CT, MRI or ultrasound of the abdominal cavity. Treatment consists in the selection of adequate antibiotic therapy. Removal of the spleen may be considered in cases of rupture or large abscesses that do not respond to antibiotic treatment. Surgery should be performed prior to valve surgery unless the latter is urgent.

Myocarditis, pericarditis

Heart failure can be a manifestation of myocarditis, which is often associated with the formation of abscesses. Complex rhythm and conduction disturbances are most often caused by myocardial damage and are an unfavorable prognostic marker. Pericarditis can be associated with abscess, myocarditis, or bacteremia, often as a result of a Staph infection. aureus. Purulent pericarditis is uncommon and may require surgical drainage. In some cases, ruptured pseudoaneurysms or fistulas can communicate with the pericardium and lead to fatal consequences.

Relapses and re-infective endocarditis

The risk of recurrent infective endocarditis among survivors ranges from 2.7% to 22.5%. There are two types of recurrences: relapse and reinfection.

A relapse is a repeated episode of IE caused by the same microorganisms as the previous fact of the disease. Re-infection is usually called endocarditis caused by other microorganisms or the same bacteria more than 6 months after the first episode. The time between episodes is usually shorter for relapse than for reinfection. In general terms, an episode of IE caused by the same species of microorganisms earlier than 6 months from the initial episode is a relapse, and later 6 months is a re-infection.

Treatment

An early start of antibacterial treatment, before the manifestations of the clinic of infective endocarditis (or rheumatic form), is the main condition for a favorable prognosis of therapy. To do this, it is necessary to use effective medical principles: "proactive", "alternative septic alertness", dispensary registration / observation of patients at risk.

The scheme of conservative antibiotic treatment:

Disease provocateur	Recommended antibiotic	Note
Not determined	Oxacillin + Cefazolin + Amoxicillin + aminoglycosides Cefazolin + aminoglycosides Cefuroxime + aminoglycosides Ceftriaxone + rifampicin Methicillin-resistant strains Str. aureus (MRSA) Methicillin-resistant coagulase-negative staphylococci Vancomycin Linezolid Ciprofloxacins + Rifampicin Rifampicin + Co-trimaxazole	In cases of effectiveness without aminoglides, it is better to do without them, given the oto- and nephrotoxicity. If you are allergic to β-lactams, you can give Lincomycin or Clindamycin. Rifampicin for intravenous administration is injected with 5% glucose (at least 125 ml of glucose). In cases of effectiveness of therapy without aminoglycosides, it is preferable to do without them. In terms of effectiveness, it is not inferior to Vancomycin.
Greening streptococci	Benzylpenicillin Ampicillin Ampicillin / sulbactam Amoxicillin / clavulanate Ceftriaxone Vancomycin
Enterococci	Ampicillin Ampicillin / sulbactam Amoxicillin / clavulanate Vancomycin, linezolid
Pseudomonas aeruginosa	Imipenem + aminoglycosides Ceftazidime + aminoglycosides Cefoperazone + aminoglycosides Ciprofloxacin + aminoglycoside Sulperazone + aminoglycosides Cefepime + aminoglycosides
Bacteria of the genus Enterobacteri acea	Ceftriaxone + Aiminoglycosides Ampicillin / sulbactam + aminoglycosides Cefotaxime + aminoglycosides Ciprofloxacin + aminoglycosides, Tienam, Sulperazon	When isolating strains of enterobacteriaceae producing extended-spectrum β-lactamases (ESBL), cardiac therapy should be continued with carbopenems (Imipenem) or inhibitor-protected carboxypenicillins.
Mushrooms	Amphotericin B Fluconazole	It is used intravenously for severe systemic mycoses, highly toxic. It is administered only on glucose.
Group of microorganisms NASEC	Ceftriaxone Ampicillin / sulbactam + aminoglycosides

Surgical intervention

The classical approach to the treatment of sepsis includes 3 main targets:

• macroorganism;
• microorganisms;
• focus of infection.

With infective endocarditis, the focus of infection is localized in the heart cavity and access to it is a technically difficult operation associated with a high risk to the patient's life. Therefore, there must be a fairly good reason for surgical treatment. Operate patients with infective endocarditis in cases where conservative treatment is ineffective. Summarizing the experience of leading domestic and foreign cardiac surgeons in the invasive treatment of active valvular infective endocarditis, we can highlight the most important signs on which the indications for heart surgery are based. The presence of at least one of the following factors dictates the need for early surgery. These include:

• progressive heart failure;
• bacteremia despite adequate antibiotic treatment for four weeks;
• repeated embolism;
• endocarditis caused by fungal flora;
• development of heart rhythm disturbances in the form of atrioventricular blockade, pericarditis, i.e. complications caused by the transition of the process to the structures surrounding the valve;
• prosthetic endocarditis;
• relapse of the disease after an adequate eight-week course of treatment with the most effective antibiotics.

Indications for surgical treatment of valvular heart diseases of infectious origin in remission are absolute in cases where the patient has indications of repeated embolism or echocardiographic examination reveals large prevailing vegetation, which are potential sources of embolism. In other cases, the indications for surgery are the same as for defects of a different genesis.

The main contraindication to invasive treatment is the severe general condition of the patient. Surgical treatment is contraindicated in patients with septic shock that cannot be stopped by drug therapy, as well as those in a coma after septic embolism into the vessels of the brain. The surgical method reflects the main principle of treatment of the infectious process and sepsis, which consists in removing the focus of infection against the background of general antibiotic therapy. The correction of hemodynamics made at the same time contributes to the normalization of blood circulation, elimination of the risk of arterial embolism, and thus puts the body in conditions that facilitate the fight against such a serious disease as acute and subacute septic endocarditis.

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Endocarditis - a disease that affects the inner lining of the heart, as well as the aortic and heart valves... This is a serious, life-threatening pathology, characterized by rapid development, the danger of embolism of blood vessels, internal vital organs and the development of immunopathological processes.

Endocarditis is classified as infectious (bacterial) and non-infectious. Although in the overwhelming majority of cases, endocarditis is infectious in nature, there are pathologies that develop as a reaction to metabolic changes within the framework of the immunopathological process or with mechanical damage to the heart.

Non-infectious endocarditis includes:

• Atypical warty endocarditis with;
• Rheumatic endocarditis;
• Endocarditis with rheumatoid, reactive arthritis;
• Leffer's fibroplastic endocarditis;
• Nonbacterial thrombotic endocarditis.

Almost always, the above diseases are an indicator that the risk of developing infective endocarditis (IE) in these cases is extremely high, namely, it poses the greatest danger to the patient's life.

Reasons for the development of infective endocarditis

The disease is rare, but recently there has been a steady trend towards an increase in the development of IE, which is associated with an increase in the resistance (resistance) of bacterial microflora to antibiotics as a result of mutations. Another reason for the increase in the number of septic endocarditis is the increase in the number of people taking intravenous drugs.

Most often, pathogens of this disease are pathogenic gram-positive microorganisms: in most cases, these are staphylococcal, streptococcal, enterococcal infections. Much less often, its development is provoked by other microorganisms, among which there may be gram-negative bacteria, rare atypical pathogens and fungal infections.

The defeat of the cardiac membrane in IE occurs with bacteremia. Synonymous with the concept of "infective endocarditis" are definitions such as septic or bacterial endocarditis. Bacteremia (presence of bacteria in the blood) can develop under favorable conditions even after the most harmless procedures.

Procedures with a high risk of developing bacteremia are:

1. Dental operations with damage to the mucous membranes of the mouth and gums;
2. Performing bronchoscopy using rigid instrumentation;
3. Cystoscopy, manipulations and surgical interventions on the organs of the urinary system, if there is an infectious component;
4. Biopsy of the urinary tract or prostate gland;
5. Surgery on the prostate gland;
6. Adenoidectemia, tonsillectomy (removal of tonsils and adenoids);
7. Operations performed on the biliary tract;
8. Previous lithotripsy (destruction of kidney stones, urinary, gall bladder);
9. Gynecological operations.

Cardiologists identify risk groups that have preconditions for endocardial inflammation, for which antimicrobial therapy is needed to prevent endocarditis.

The high-risk group includes:

• Patients with previous bacterial endocarditis;
• Operated for heart valve replacement, if mechanical or biological materials were used;
• Those with congenital and acquired complex disorders with aortic and cardiac ventricular disorders - the so-called "blue" defects;

The following categories of patients are at moderate risk:

• Patients with;
• With hypertrophic;
• Having all other heart defects (congenital and acquired) that do not fall into the first risk group, without cyanosis.

Patients with the following diagnoses are less at risk of developing this disease:

• and vessels;
• Defect of the interatrial and interventricular septum, including the operated one, in the period up to six months after surgery;
• Implanted pacemakers and defibrillators;
• without damage to the valves.

Video: Endocarditis. Why is it so important to have your teeth treated on time?

How does IE develop?

The period from the penetration of infection to the development of the IE clinic is different - from several days to several months. It depends on the virulence of the pathogen, the state of the patient's immune system and the heart.

Inside the heart cavity, the pathogen settles on the valve flaps and begins to grow, while colonies of microorganisms are formed (vegetation). In addition to microorganisms, they contain erythrocytes, leukocytes, platelets, fibrin. As the infection progresses, the surface of the valves deforms, forming a bumpy surface or ulcers with thrombotic overlay.

When the deformation reaches a significant size, heart valves lose their ability to close tightly, which leads to the development of hemodynamic disorders and the emergence of acute heart failure. This condition develops rapidly and is a danger to the patient's life. Destroyed pieces of leaflets, fragments of colonies of microorganisms can come off from the destroyed valve. With the blood flow, they are carried along the small and large circle of blood circulation, can cause ischemia of important organs and, which is accompanied by various neurological disorders, paresis and paralysis and other serious complications.

Endocarditis classification

When making a diagnosis, the doctor must formulate a more accurate diagnosis that characterizes the main features inherent in this type of disease, which makes it possible to get a more accurate and detailed idea of \u200b\u200bthe course of the disease.

1. According to the activity of the pathological process, active, healed, recurrent endocarditis is distinguished;
2. By the likelihood and certainty of the diagnosis (probable or certain);
3. By the type of infectious agent (identified or not established);
4. By the nature of the affected valve, if there is prosthetics.

Also, several types of course and severity of the inflammatory process are distinguished, taking into account the initial characteristics of the damaged valves.

• Acute septic endocarditis can develop within a matter of hours or days, it is characterized by severe hectic fever, rapid development of complications in the cardiovascular system. It is distinguished by acute IE and a pronounced ability to penetrate the surrounding tissues, which is due to the type of pathogen with a high level of virulence;
• Subacute infective endocarditis develops more slowly, from the penetration of the pathogen into the heart cavity to clinical manifestations, it takes from several weeks to several months. Its course is more favorable, since its pathogen is less aggressive and capable of penetrating into surrounding tissues.

In addition, the disease is classified into the following types:

1. Primary IE - the initially intact endocardium is affected;
2. Secondary IE - is able to develop against the background of the existing heart pathology.
3. The so-called "prosthetic" IE - develops when an artificial heart valve is infected.

IE in children, symptoms

In young children, from the neonatal period to 2 years, development of congenital IE is possible... As the cause of this disease are infectious diseases of the mother or intrauterine infection of the fetus. Perhaps the development of acquired endocarditis in children, as a complication of meningococcal infection, salmonellosis, brucellosis, scarlet fever, HIV. More often in children, the aortic valve is affected, inflammation leads to destructive changes, perforation, rupture of the valves. The course of this disease is difficult for children, there is a high risk of complications and death.

Signs and methods for diagnosing IE

Septic endocarditis begins acutely. Suddenly, body temperature rises to 39-40 C, severe chills, pain in muscles and joints occur. The mucous membranes and skin turn pale, small rashes appear on it (hemorrhagic rash), there are nodular rashes on the soles of the feet and palms of a crimson hue (Osper's nodules), which disappear a few days after the onset of the disease. If an infection joins, then the rashes suppurate, and later on, their scarring occurs. The fingers of the upper and lower extremities thicken to the nail phalanges, they take on a characteristic appearance, known as "drumsticks", and the nails - "watch glasses". There may be hemorrhages under the nails in the form of stripes of reddish-brown color.

When listening to heart sounds, extraneous noises are clearly defined, having different tones and loudness, depending on the degree of valve damage, heart failure is often simultaneously diagnosed.

If the right heart is affected and a lung infarction has developed, pleurisy, hemoptysis and pulmonary edema may develop. Almost always, patients experience kidney damage in the form of nephritis, there is a risk of developing renal failure. Not less often, damage to the spleen, liver develops with the development of hepatitis, abscess or liver infarction. In some cases, eye damage occurs, which can lead to blindness. Often there are manifestations of arthralgia, with the development of periostitis, hemorrhage and embolism of the vessels of the periosteum, patients complain of pain in the bones.

These are classic signs of endocarditis, but sometimes they are modified or partially absent. To clarify the diagnosis, it is necessary to identify the presence of a pathogenic microorganism in the blood, for which arterial blood is examined by laboratory methods. Vegetation of microorganisms on the heart valve can be detected using. Often, at the initial stage of the disease, endocarditis cannot be recognized, since such or similar symptoms can accompany other acute infectious diseases.

figure: signs and complications of endocarditis

If IE is suspected, the physician should evaluate all signs of the disease in aggregate. If the first blood culture does not give a positive result, it is repeated, repeatedly. Also, if this disease is suspected, it is necessary to prescribe an echocardiogram, since this is the most informative method that allows you to detect and visualize pathologies of the heart valve and the growth of microorganisms. In the course of treatment with EchoCG, the effectiveness of the therapy is monitored. In some cases, according to indications, a diagnostic biopsy of the endocardium is performed in order to confirm the diagnosis.

• Biochemical and general blood tests confirm the ongoing inflammatory process in the body;
• Chest x-ray detects changes in the lungs when;
• Ultrasound of the heart allows you to visually determine the presence of IE and describe it in detail.

Video: infective endocarditis on echocardiography

In the video: tricuspid valve infective endocarditis, vegetation. Echocardiography, apical access.

Treatment for infectious and non-specific endocarditis

After confirming the diagnosis of IE the doctor prescribes massive antibiotic therapy: the patient is injected with antibiotics in large doses intravenously. After determining the pathogen, it is necessary to choose the most effective drug capable of suppressing pathogenic microorganisms, for this, the endocarditis pathogen is inoculated in a sterile environment in the laboratory and exposed to several drugs. Treatment for endocarditis is carried out for a long time, for 1.5-2 months until the infection is completely destroyed, which must be confirmed by repeated microbiological blood tests, monitoring the patient's condition, EchoCG data, ultrasound and other diagnostic methods.

Endocarditis of fungal origin is more difficult to treat. Most often they are detected in weakened patients with suppressed immunity, who previously received long-term ineffective antibacterial treatment; in patients with chronic systemic diseases: malignant tumors, HIV infection,. With severe heart failure, a decision may be made to perform a surgical intervention on the heart and excision of microbial growths.

With the appointment of antibiotic treatment, acute manifestations of the disease may subside, however, if the microorganisms are resistant to antibiotics, they are able to become covered with a protective film under which the infection persists. This period can last for a long time, when suitable conditions occur, the film is destroyed, microorganisms are reactivated, which causes a relapse of the disease within 2-3 weeks after the end of treatment.

At the same time, symptomatic therapy is carried out to maintain the patient's cardiac activity, relieve the phenomena of intoxication, and prevent the formation of blood clots. All activities should be carried out with constant monitoring of the blood composition in order to see the dynamics of the disease in time.

If valvular defect, life-threatening heart failure, vascular embolism, or foci of infection outside the valvular ring occur during IE, doctors may decide on the need for surgery during the active phase of the disease in order to save the patient's life. During surgery, surgeons correct the valve defect, suture the torn flaps. If the valves are completely destroyed, they can be carried out.

Photo: mitral valve replacement

When treating non-infectious endocarditis, great attention should be paid to the treatment of the underlying disease.... To eliminate vegetation, anticoagulant drugs are prescribed, which contribute to their disappearance.

What is the prognosis for endocarditis?

Until recently, until antibiotic and chemotherapy therapy was introduced into practice, the prognosis for this disease was extremely unfavorable, there was a high mortality rate among patients, and there were isolated cases of recovery. Currently, the prognosis depends on many accompanying factors.

Under favorable circumstances, 55 to 85% of all patients are cured with this diagnosis. To a greater extent, the course of the disease and prognosis depend on the aggressiveness and pathogenicity of the infectious agent and the patient's susceptibility to infection.

Regardless of the severity of the disease, endocarditis in most cases affects the entire further life of a person, since in the future there will always be a risk of developing a heart valve defect and associated complications. These include the development of myocarditis - inflammation of the middle layer of the heart muscle, which bears even more serious consequences, since it can lead to the development of cardiomyopathy, the rapid development of heart failure and heart rhythm disturbances. This condition may require additional symptomatic therapy. A great danger is renal failure and the resulting intoxication of the body.

Prevention of the disease

In order to minimize the risk of developing this formidable disease, you should adhere to simple rules and monitor your health:

1. It is necessary to promptly sanitize the foci of infections in the body, treat caries, diseases of the nasopharynx. You need to be attentive even to the most common chronic diseases - tonsillitis, sinusitis, rhinitis; acute and chronic kidney diseases require special treatment and attention.
2. After the performed surgical interventions in persons in risk groups, it is necessary to carry out antibacterial therapy with a prophylactic purpose. Operations also include all dental procedures, including manipulation of the gums in violation of the oral mucosa.
3. Avoid stressful situations, excessive physical and psychological stress, acute viral infections;
4. After suffering infectious endocarditis, patients should be on permanent dispensary registration with a cardiologist, timely undergo rehabilitation therapy courses in sanatoriums;
5. You need to purposefully strengthen your immunity, for this you need to eat well, lead a healthy lifestyle and regularly take multivitamins;
6. Timely immunization against mumps, measles, rubella viruses is of great benefit in preventing the development of complications;

Patients with infectious endocarditis should carefully monitor their health throughout their lives, then they will be able to lead a full, active lifestyle without fear of a relapse of the disease.

Video: lecture on infective endocarditis

Infective endocarditis is characterized by damage to the inner lining and valves of the heart, the aortic valve mechanism. Against the background of the disease, heart failure, embolism of the circulatory system, diseases of other internal systems and organs are rapidly developing. Pathology refers to a severe form in which a lethal outcome is possible.

General characteristics, types and forms

An infectious nature is inflammation of the endocardium (inner lining). It occurs against the background of infection with pathogens of various agents. Most often, pathology occurs in men, the age-related feature for infection is not typical. The incubation period directly depends on the type of pathogen, therefore it can range from several days to months. Also, this process is influenced by the state of the immune system of an infected person - the stronger the immunity, the longer the bacteria do not manifest themselves.

Pathogenic microorganisms enter the endocardium through blood fluid. Initially, they are localized in the heart chamber and cavity, attaching to the valve cusps. Then they grow, forming whole colonies. This vegetation process leads to deformation of the valves, the formation of lumpy surfaces and ulcers that contain thrombotic overlays. With significant damage, the valve system stops closing, which is why hemodynamic disorders develop, leading to heart failure.

The main danger lies in the rupture of the valve leaflets, pieces of which can be carried along the small and large circles of blood circulation. And this causes ischemic damage not only to the heart, but also to the brain and other internal organs. Ischemia, in turn, leads to neurological disorders, paralysis, paresis, etc.

Classification by the type of severity of infective endocarditis:

• An acute septic course develops very quickly. Sometimes a few hours are enough. Complications develop just as quickly, which is dangerous to human life. If the pathogen has a high level of virulence, then it penetrates even into the tissues of nearby organs. The main bacteria are staphylococci.
• The subacute course is characterized by slow development. It can take several weeks, and sometimes months, from the day of infection until the first symptoms appear. Surrounding tissues are not affected, the bacterium does not show aggression. The most common causative agent is streptococcus and Staphylococcus aureus.
• Prolonged flow.

Forms of the disease:

• the primary form is the defeat of endocarditis for the first time;
• secondary form - the development of the disease occurs due to the presence of diseases of the cardiovascular system;
• prosthetic form - the implant becomes infected (artificial valve).

Other classifications of infective endocarditis:

• the disease can be active, cured, and relapsing;
• the diagnosis can be probable or certain;
• type of pathogen - installed or not detected.

Infective endocarditis, which occurs in the right heart, most often develops in drug addicts, because skin bacteria enter the bloodstream.

The reasons

To date, the incidence of viral and bacterial endocarditis has increased significantly. This is due to two main reasons: firstly, the number of drug addicts has increased, and secondly, viruses and bacteria mutate over time, adapting to any conditions. Pathogens are becoming more resistant to antibacterial and antiviral agents.

The main gram-positive pathogens:

• staphylococcus aureus;
• enterococcus;
• streptococcus;
• candida;
• coxiella.

Not only the above-mentioned pathogens can become causative agents of infective endocarditis. It turns out that any bacteria can be the cause. These can be gram-negative pathogens, fungi, atypical bacteria.

Bacteria begin to multiply actively only under the condition of a favorable environment, which occurs in such cases:

• damage to the gums and oral mucosa (at home or dentistry);
• bronchoscopy - hard instrumentation damages surfaces;
• surgical intervention or diagnostic measures that are performed on the urinary organs;
• damage to the genitourinary system of women and men during surgery and research:
• tonsillectomy or adenoidectomy;
• manipulation of the biliary tract;
• lithotripsy;
• gynecological surgery.

At-risk groups:

• people who have already suffered a bacterial type of endocarditis;
• patients who underwent implantation of the valve system: most often, infection occurs when using mechanical and biological materials;
• people with congenital and acquired heart defects, often in the presence of disorders in the heart ventricles and aorta;
• the presence of mitral valve prolapse;
• hypertrophic cardiomyopathy;
• ischemia of blood vessels and heart;
• the presence of pacemakers and defibrillators;
• rheumatic attacks;
• atrial and interventricular defects in the septa.

Infective endocarditis symptoms

The main symptom of the disease is a febrile condition. The temperature rises gradually.

The following signs are also observed:

• general weakness;
• fatigue;
• feeling chills;
• night sweats;
• weight loss;
• joint pain and back pain.

Chronic forms viral endocarditishave the following symptoms:

• change in complexion (pallor);
• high temperature (up to 38 degrees);
• rapid breathing and heartbeat;
• blood points in the eyes;
• development of conjunctivitis;
• dermatological formations throughout the body;
• darkening of the nails;
• if the disease is not treated for a long time, then the digital phalanges are modified - they become thick.

A long course of the disease can lead to the following symptoms:

• enlargement of internal organs (mainly the spleen);
• swelling of the limbs.

Right-sided bacterial endocarditis characterized by:

• inflammatory process of the walls of blood vessels;
• fever;
• chest pain;
• bloody coughing up;
• pulmonary edema.

Diagnostics

Diagnostic measures for infective endocarditis are aimed at identifying the main cause of the pathology and the pathogen itself. It is also important to carry out symptomatic therapy. Therefore, the following survey methods are used:

• Laboratory diagnostics involves the collection of blood tests, and sometimes urine. Bacteria are identified, their type is determined.
• Instrumental and hardware diagnostics examines the heart, circulatory system and, if necessary, other internal organs. It is possible to determine the cause of the development of pathology and the degree of damage by pathogens, on the basis of which adequate therapy is prescribed.

Infective endocarditis treatment

Drug treatment

The first step is to eliminate the pathogen. For this, antiviral drugs, antibiotics or antifungal drugs are used. Drug therapy is carried out immediately after the pathogen is identified.

The following groups of drugs are used:

• for any type of staphylococcus, the following antibacterial drugs are used: "Ceftriaxone", "Benzylpenicillin", "Gentamicin", "Vancomycin", "Amoxicillin", "Ampicillin", "Cefazolin", "Linezolid", "Imipenem", "Oxacillin";
• with enterococci: "Ampicillin", "Benzylpenicillin", "Gentamicin";
• for pneumococci: "Levofloxacin", "Cefotaxime", "Linezolid";
• in case of NASEC bacteria: "Ampicillin", "Gentamicin", "Ceftriaxone";
• with Pseudomonas aeruginosa - only "Ceftazidime";
• with fungal infection: "Flucytosine", "Meropenem", "Amikacin", "Amphotericin B".

The duration of drug therapy is from 2 weeks to 2 months, depending on the extent of the lesion. The dosage is prescribed exclusively by the attending doctor, taking into account the individual characteristics of the course of the disease and the body.

It is also necessary to get rid of high body temperature, reduce the level of ESR and other substances in the blood, neutralize symptoms, and also prevent further growth and spread of the pathogen. Therefore, the following complex therapy is used:

• to eliminate inflammatory processes, glucocorticosteroid medications are used, mainly Prednisolone;
• angiotensin-converting enzyme inhibitors;
• diuretic drugs;
• a group of glycosides;
• beta and adrenergic blockers;
• antiplatelet agents;
• aldosterone antagonists.

These drugs have a beneficial effect on the cardiovascular system, improving its functionality, reducing stress, preventing the formation of blood clots.

Surgical treatments

Surgical intervention is used only in extreme cases, when medical treatment does not make sense, as well as in the presence of complications. The main indications for surgery for infective endocarditis:

• the development of heart failure, which is not treated with medication;
• purulent accumulations in the endocardium;
• the presence of a mechanical valve;
• an excessive number of colonies of the pathogen.

Today, the most commonly used rehabilitation techniques of surgery. For example, a thoracotomy, in which the chest is opened, and the heart is connected to a pumping equipment that performs the function of artificial circulation. Sanitation is carried out in the following ways:

• mechanical removal of pathogen colonies and affected areas of the heart;
• antiseptic treatment of parts of the heart in a chemical way;
• ultrasonic sanitation of tissues and organs that are inaccessible for removal.

If the affected valves have been removed, the doctor must replace them with artificial organs. But this procedure is done separately from thoracotomy.

Surgical intervention does not guarantee the complete elimination of the pathogen, therefore, drug therapy is used in any case.

Prognosis, possible complications

Even with proper treatment and complete recovery, the patient may develop complications after a while. Experts always warn about possible changes in health status. The main complications after infective endocarditis are the following:

Chronic heart failure

It is considered a serious pathology in which the heart is unable to pump the required amount of blood. This is due to a violation of the muscle tissue of the heart and its valves. With heart failure, circulation is impaired, which leads to a decrease in the level of oxygen in the blood. This complication can be treated with surgery. Doctors replace the affected heart valve with an artificial implant. If it was possible to get rid of bacterial endocarditis in a timely manner, then the degree of complication will decrease.

Blocked arteries with blood clots (thromboembolism)

Such a complication can cause death of the patient. Blood clots form on the walls of the valves. They can be mobile or evolving. The risk of entering the bloodstream is very high. If thromboembolism develops in the right ventricle, when moving, the thrombus enters the small circles of blood circulation. Blockage occurs in the vascular system of the lungs, which disrupts oxygen exchange. If a thrombus develops in the left side of the heart ventricle, blockage can occur in different parts of the body. Such movements of a blood clot through the circulatory system are life-threatening, a person dies without urgent medical attention.

The vessels from the left ventricle that are most susceptible to clogging with thrombi are:

• spleen arterial valve;
• arteries of the brain;
• limb vessels;
• intestinal arteries;
• eye vessels.

To detect thromboembolism, specialists prescribe an EchoCG. The blood clots are removed or prevented.

Long process of infection

After suffering infective endocarditis, bacteria continue to develop in the heart. Microorganisms become the causes of complications. Prolonged circulation of viruses can damage internal organs and tissues. The patient feels unwell, weak, experiences fever, pain in the head and muscles. Treatment is expensive and time consuming.

In this case, such violations occur:

• spleen and heart infarction;
• pulmonary abscesses, hypertension, edema and pneumonia;
• hepatitis;
• pericarditis, and even heart abscesses;
• meningitis and cysts;
• thrombophlebitis, aneurysms, vasculitis and thrombosis in the circulatory system;
• heart failure.

Prevention

Infective endocarditis is not transmitted in any way, so the risk of infection is zero. In order to avoid the appearance of this disease, you should adhere to the following tips:

• try not to overcool;
• do not carry infectious diseases "on your feet";
• lead an active lifestyle;
• go in for sports;
• exclude alcohol and smoking;
• follow the correct diet;
• exclude contacts with patients with acute respiratory viral infections;
• in the presence of infectious pathologies of any organs, seek help from a specialist;
• perform diagnostic measures and operations in clinics with a good reputation, this will reduce the risk of infection during the procedure;
• get rid of diseases of the cardiovascular system;
• visit doctors more often.

The opinion of doctors about endocarditis - video

How does infective endocarditis develop, what are its symptoms and causes, what treatments are used? See our video about this and much more:

A weakened immune system also contributes to the development of infective endocarditis. Therefore, it is necessary to monitor the state of the immune system - to consume more natural vitamins, to enrich the body with minerals and trace elements. At the first signs of the disease, you should contact the clinic.

Infective endocarditis is an inflammatory process of infectious origin that affects the inner lining of the heart (endocardium), which lines its chambers and valves.

The incidence of infective endocarditis, according to different authors, ranges from 3 to 10 cases per 100,000 population. Women get sick half as often as men.

Infective endocarditis is an infectious polyposis-ulcerative inflammation of the endocardium

Causes and risk factors

For the development of infective endocarditis, a combination of several factors is necessary:

• damage to the endothelium of blood vessels and endocardium;
• transient bacteremia (temporary circulation of pathogenic or opportunistic microorganisms in the bloodstream);
• decreased general immunity;
• violation of hemodynamics and hemostasis.

The cause of transient bacteremia usually lies in the focus of chronic infection in the body or in the performance of invasive (that is, those occurring with damage to the integrity of the skin) medical procedures.

The most common causative agent of the subacute form of infective endocarditis is green streptococcus.

The acute form of the disease can be caused by:

• staphylococcus aureus;
• pneumococcus;
• enterococcus;
• escherichia coli.

Infectious endocarditis caused by fungal infection, anaerobic and gram-negative pathogens are very difficult. The cause of fungal endocarditis is long-term antibiotic therapy or a long-standing catheter in the vein.

Microorganisms circulating in the bloodstream penetrate into the cavity of the heart and adhere to the endocardium. This process is called adhesion, the conditions for its course are impaired immunity, as well as congenital or acquired defects of the valve apparatus.

Infective endocarditis is fraught with serious complications that can lead to death: acute heart failure, septic shock, multiple organ failure, etc.

Hemodynamic disturbances caused by heart defects contribute to the occurrence of microtraumas of the endocardium and valves. Through these injuries, infectious agents enter the endocardium. Microbial colonies very quickly destroy the valves, as a result of which they can no longer perform their functions, and the patient develops rapidly progressive heart failure.

Against the background of infective endocarditis, an immune damage to the endothelium (inner layer) of the capillaries of the mucous membranes and skin occurs. This is manifested by symptoms of hemorrhagic capillarotoxicosis or thrombovasculitis.

Forms of the disease

Depending on the cause of infective endocarditis, it happens:

• primary - the infectious process in the endocardium develops against the background of initially unchanged valves;
• secondary - an infection in the endocardium develops against the background of an already existing pathology of the valve apparatus or blood vessels.

By the nature of the course, the following forms of infective endocarditis are distinguished:

• acute - arises as a complication of medical manipulations on blood vessels, heart or acute septic condition, lasts 1.5-2 months;
• subacute - occurs with insufficiently active treatment of the underlying disease or acute form of endocarditis, lasts more than 2 months;
• protracted - characterized by a slow course and the absence of an obvious primary purulent-septic focus.

According to the activity of the inflammatory process, infective endocarditis can be active and inactive (healed).

The inflammatory and destructive process can be limited (only the leaflets of the heart valve are affected) or go beyond the affected valve.

Disease stages

In the clinical course of infective endocarditis, several stages are distinguished:

1. Infectious and toxic. It is characterized by transient bacteremia and the formation of microbial vegetations (colonies) on the valves of the heart and endocardium.
2. Immuno-inflammatory (infectious-allergic). Symptoms of damage to internal organs are characteristic, that is, signs of splenomegaly, nephritis, hepatitis, myocarditis.
3. Dystrophic. It develops against the background of progressive heart failure and septic process. It manifests itself as severe irreversible lesions of internal organs, including myocardial necrosis.

Without treatment, infective endocarditis is fatal within 1.5-6 months from the onset of the first symptoms.

Symptoms

The acute form of infective endocarditis is clinically characterized mainly by signs of toxemia and bacteremia. These include:

• severe general weakness;
• increased fatigue;
• decreased appetite;
• loss of body weight;
• dyspnea;
• an increase in body temperature to high values, which is accompanied by tremendous chills;
• profuse sweating with a decrease in body temperature;
• iron-deficiency anemia;
• earthy skin color;
• petechiae (small punctate hemorrhages) on the mucous membranes and skin;
• a pinch symptom (bruising with minor skin trauma).

Against the background of infective endocarditis, most patients have damage to the heart muscle itself (myocarditis). During auscultation of the heart, functional murmurs are heard, the appearance of which is explained by valve damage and anemia.

The defeat of the aortic and (or) mitral valves is accompanied by the appearance and progression of signs of their insufficiency, as well as heart failure.

With subacute infective endocarditis, thrombotic overlays break off from the leaflets of the affected heart valves, as a result of which an embolism of the blood vessels of the spleen, kidneys, and brain may occur with the formation of a heart attack (necrosis) of these organs. The examination reveals:

• enlargement of the liver and spleen (hepatosplenomegaly);
• polyarthritis;
• diffuse (less often focal) glomerulonephritis.

Diagnostics

When collecting anamnesis, special attention should be paid to previous medical interventions and the presence of foci of chronic infection. Confirmation of the diagnosis of infective endocarditis is carried out according to the data of laboratory and instrumental examination of the patient, including:

• general blood test (leukocytosis, shift of the leukocyte formula to the left, a significant increase in ESR);
• bacteriological blood culture with determination of sensitivity to antibiotics. This test is repeated several times, and blood sampling is best done at the height of the fever;
• blood chemistry. Changes in the immune status are noted (the concentration of anti-tissue antibodies increases, the hemolytic activity of complement decreases) and the protein spectrum (the concentration of α-globulins increases, and subsequently γ-globulins);
• EchoCG. Helps to visualize microbial vegetation with a diameter of more than 5 mm on the heart valves;
• magnetic resonance imaging or multislice computed tomography. Allows to assess with a high degree of accuracy the condition of the valves, as well as the whole heart.

Treatment

With infective endocarditis, the patient is hospitalized; shown strict bed rest. An important element of therapy is the organization of proper nutrition. The diet should be balanced in terms of the content of nutrients, vitamins and microelements, and consist of easily digestible foods.

The main treatment is medication. Antibiotics are prescribed taking into account the sensitivity of the microflora, until the results of the antibioticogram are obtained, antibiotics of a wide spectrum of action are used.

The incidence of infective endocarditis, according to different authors, ranges from 3 to 10 cases per 100,000 population. Women get sick half as often as men.

Therapy of infective endocarditis of fungal etiology is carried out with amphotericin B for a long course (up to several months). In the complex drug therapy of the disease, other agents with antimicrobial properties (antistaphylococcal globulin, antistaphylococcal plasma, dioxidine) can also be used.

Methods of extracorporeal detoxification (intravascular ultraviolet blood irradiation, plasmapheresis, hemosorption) are shown.

In the presence of concomitant diseases (nephritis, polyarthritis or myocarditis), non-steroidal anti-inflammatory drugs are added to the therapy regimen.

When the heart valves are destroyed with the development of their failure after the inflammatory process subsides, surgical intervention is performed to replace the valves.

Possible complications and consequences

The most dangerous complications of infective endocarditis that can lead to death are:

• acute heart failure;
• respiratory distress syndrome;
• embolism in the vessels of the brain or heart;
• septic shock;
• multiple organ failure.

Forecast

The prognosis for infective endocarditis is always serious. Without treatment, the disease ends in death within 1.5–6 months from the onset of the first symptoms. With timely antibiotic therapy, the mortality rate is 30%. In about 15% of patients, infective endocarditis takes on a chronic course, in which periods of remission are followed by periods of exacerbation.

Prevention

Patients at risk for the development of infective endocarditis (with congenital or acquired heart defects, prosthetic valves, vascular pathology, foci of chronic infection in the body) should be under medical supervision.

To prevent bacteremia during invasive medical procedures, broad-spectrum antibacterial drugs should be prescribed.

Also, to prevent the development of infective endocarditis, it is necessary:

• regularly sanitize foci of chronic infection in the body;
• avoid bacterial and viral infections, and when they appear, carry out timely treatment;
• avoid hypothermia;
• adhere to proper nutrition;
• carry out hardening procedures.

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Infective endocarditis (IE, bacterial endocarditis) is a severe inflammatory disease of the heart valves with an unfavorable prognosis and the formation of persistent complications that affect the patient's quality of life in the future. The heart tissue is attacked by pathogenic microbes.

It is an independent disease, unlike other endocarditis, developing as a manifestation or complication of other diseases. The main danger is the absence of characteristic symptoms. At an advanced stage, the percentage of deaths is high. How to recognize the disease in time? What treatments are there?

In bacterial, fungal or viral infective endocarditis, bacteria or other microorganisms affect the inner layer of the heart membrane - the endocardium and heart valves.

Bacteria or fungi penetrate the heart tissue and form their colonies. As a result, blood clots are formed, inflammatory foci occur, heart tissue is destroyed... Sometimes microorganisms are carried with the blood to the organs, disrupting the blood flow in them.

If the disease is not detected in time and timely medical care is not provided, the risk of death is very high.

The presence of bacterial or fungal accumulations in the heart interferes with the functioning of this important organ. The patient must be treated under medical supervision.

ICD-10 code

According to ICD-10, the pathology of bacterial infective endocarditis has the code I33.0, regardless of whether it is a subacute form or an acute one. If it is necessary to identify the infectious agent, then additional codes (B95-B98) apply, where:

• B95 - staphylococci and streptococci.
• B96 - Other specified bacterial agents.
• B97 - viral agents for endocarditis.
• B98 - Other specified infectious agents.

Prevalence statistics of bacterial pathology

In the last 40-50 years, the number of patients with bacterial infective endocarditis has increased dramatically. This is associated with an increase in the number of injections and surgical interventions in the body, which creates additional pathways for infections and bacteria to enter.

In different countries the disease occurs in 3-10 people out of 100 thousand, and for people over 70 years old this figure is 14.5 per 100 thousand.

Most often people with artificial devices inside the heart (pacemakers, valve prostheses) and heart problems are ill.

Incidence rates are higher in developed countries. Men are 2 times more likely to be affected by this disease.

Etiology: causes of the disease

IE causative agents are microbes, fungi, viruses, more often bacteria (because of this, infective endocarditis is also called bacterial):

• Streptococci (primarily greening) and staphylococci - up to 80% of cases.
• Gram-negative bacteria Haemophilus species, Actinobacillus actinimycetecomitans, Cardiobacterium hominis, Eikenella corrodens, Kingella kingae. By capital letters of their names, they are grouped under the term "HACEK".
• Mushrooms Aspergillus, Candida, Chlamydia, Rickettsia, etc.
• Viruses.

The onset of infective endocarditis is always preceded by intervention or manipulation, which can lead to the entry of microorganisms into the bloodstream. That is, transient bacteremia occurs.

A bacterial or fungal infection can develop even with simple brushing, which is accompanied by bleeding, tooth extraction, and other dental interventions. The reason may also be operations on the genitourinary tract, biliary tract, ENT organs, gastrointestinal tract. Also, the reasons are as follows:

• intravenous jet and drip administration of drugs;
• any surgical intervention;
• medical manipulations, in which the introduction of microbes is possible: bronchoscopy (examination of the respiratory tract), cystoscopy (examination of the bladder), catheterization of the urethra, abortion, etc.;
• injecting drug use.

Classification

Pathogenesis: features of the development of acute and subacute forms

The disease develops as a result of bacteremia, i.e. getting into the systemic circulation of pathogens.

In response to antigens of the pathogen in the bloodstream, antibodies are formed, as a result of which toxic immune complexes enter the blood. Their exposure triggers hypersensitivity reactions. In this way, for the development of the disease, a combination of 2 factors is necessary:

• bacteremia - circulation of the pathogen in the blood;
• autoimmune process - sensitization of the body to the pathogen.

As a result of bacteremia, pathogens reach the heart valves and can attach to the endothelium., especially if there is damage to the heart valves or thrombotic deposits, which become an excellent springboard for the deposition of microbes. An infectious focus arises at the site of attachment, which results in valve destruction and ulceration.

There are three stages in the development of infectious bacterial, fungal or viral endocarditis:

• Infectious and toxic. It differs in transient bacteremia with the accumulation of bacteria on the damaged endocardium, microbial vegetations are formed.
• Immunoinflammatory. A detailed picture of organ damage is noted.
• Dystrophic. Severe and irreversible organ changes are formed due to the progress of sepsis and heart failure.

Since microorganisms most often affect heart valves already damaged by any disease, it is possible to distinguish factors predisposing to the development of bacterial endocarditis:

• Scars on the heart valves after a fever;
• Congenital heart defects:, etc .;
• Acquired defects: or;
• Valve calcification as a result;
• Cardiomyopathy;
• Artificial heart valve;
• Mitral valve prolapse;
• Marfan's syndrome (hereditary autosomal disease);
• A history of endocarditis.

Clinic: symptoms and signs in adults

Common symptoms are due to an infectious process, their severity depends on the type of pathogen:

• fever: temperature 38.5 - 39.5 ºC. It is important to know the features and how long the temperature lasts for infective endocarditis. Differs in two peaks during the day;
• chills, profuse sweating, especially at night;
• tachycardia associated with both a rise in temperature and heart failure;
• dyspnea;
• with subacute infective endocarditis, the skin color is pale; in severe cases, it can be pale gray with an icteric tinge (the color of coffee with milk);
• weakness, fatigue, constant feeling of tiredness;
• loss of appetite, weight loss;
• joint and muscle pain;
• hemorrhagic rashes on the mucous membranes and skin.

Acute infective endocarditis is manifested by the following symptoms:

• The body temperature rises sharply. Leap up to 40 °.
• The patient has a fever, sweating increases.
• The symptoms of general intoxication of the body are pronounced. Such as an enlarged liver, severe headache, hemorrhages on the skin and mucous membranes, a decrease in the speed of reactions.
• Perhaps the appearance of small painful formations on the palms, feet - Osler's nodules.
• In places of infection, the development of abscesses is characteristic.

With inflammation in the walls of an artery, there is a high probability of rupture, which is fraught with internal hemorrhages. It is especially dangerous if the vessel is in the heart or in the brain.

Subacute infective endocarditis does not develop as rapidly... The patient can walk for months until a critical condition occurs, which will determine the problem.

Symptoms that should alert you:

• Unreasonable increase in body temperature by 1-2 degrees. Chills.
• Fast fatiguability.
• Weight loss. Decreased or lack of appetite.
• Heavy sweating.
• The development of anemia is a decrease in the number of red blood cells in the blood.
• When listening to the heart, you can distinguish a new murmur or a change in the nature of the murmur.
• Small spots similar to freckles appear on the skin, whites of the eyes, under the nail plates. These are the results of small hemorrhages, as a result of throwing an embolus into a small vessel - particles of bacteria, pus, blood clots.
• Blockage of arteries in the limbs, heart attack or stroke is possible.
• Symptoms of acute heart failure appear.

Also characteristic peripheral signs of infectious bacterial endocarditis can be distinguished:

• Lukin-Libman spots - petechial rashes on the mucous membranes of the oral cavity, conjunctiva and folds of the eyelids;
• Osler's nodules are cherry-red thickenings on the hands and feet;
• Drum fingers - the terminal phalanges of the fingers take the form of drumsticks, nails - watch glasses;
• Janeway's spots - hemorrhages in the skin and subcutaneous fatty tissue, prone to ulceration;
• Roth spots are retinal hemorrhages with a pale spot in the center.

Not all of these signs can be found in a patient, but the presence of even one of them is a serious reason to suspect bacterial endocarditis.

Emboli can cause chest pain due to pulmonary infarction or myocarditis, kidney damage in the form of hematuria, glomerulonephritis, etc., pain in the upper and lower extremities and paralysis, sudden loss of vision, cerebral circulation disorders due to cerebral ischemia, headache, abdominal pain, myocardial infarction, kidney, spleen, lungs, etc. .d.

On palpation, there is often an increase in the spleen (splenomegaly) and liver (hepatomegaly).

When auscultation in a patient with bacterial, fungal or viral endocarditis, pronounced heart murmurs are heard due to thrombotic overlays. Signs of heart failure appear later as manifestations of the defects of the valve apparatus formed during the disease.

With damage to the right heart, in addition to general symptoms, there are:

• chest pain;
• hemoptysis;
• pulmonary heart attacks.

Thromboembolic syndrome is rare in right-sided EB.

Read more about the causes and symptoms of the disease in this video:

Is the development of the disease possible in children?

Infectious bacterial endocarditis is considered a dangerous and difficult to diagnose disease, which is often the cause of death in children. A particular danger in this pathology has arisen due to the increase in the number of pediatric operations on blood vessels and heart.... The disease threatens children with long vein catheterization, with problems of immunity.

IE is able to develop on healthy heart valves, but more often it overlaps existing problems and defects (90%). According to statistics, boys get sick 2-3 times more often than girls. The exact incidence of the disease in children is unknown, but the number of sick children is gradually increasing, amounting to 0.55 per 1000 hospitalized.

Infective endocarditis in children is congenital and acquired. Congenital develops if the mother has infections, acting as one of the types of sepsis. The acquired form is often found in children under 2 years of age on healthy valves, and in older ones - on affected ones, with defects.

Diagnostics

A typical clinical picture is that when several signs of bacterial endocarditis are found, the diagnosis is usually not difficult. So, for example, the presence of fever, enlargement of the spleen, skin hemorrhagic rashes, hematuria in combination with murmurs in the heart indicate an infectious process taking place in it. Consider the methods of differential diagnosis of infective endocarditis.

Laboratory methods

A blood test for infectious bacterial endocarditis determines:

• Moderate normochromic anemia (often with subacute IE).
• Increased ESR (erythrocyte sedimentation rate), often up to 70-80 mm / h. Here, an answer should be given to the question of how long the ESR decreases after endocarditis: despite the treatment, an increase in this indicator persists for 3-6 months. At the same time, the presence of a normal ESR level does not exclude the problem.
• Leukocytosis, in which the leukocyte formula shifts to the left (an increase in the number of "young" neutrophils).
• Dysproteinemia with an increase in the level of gamma globulins, less often alpha-2-globulins.
• Circulating immune complexes.
• C-reactive protein.
• Rheumatoid factor (in 35-50% of patients with a subacute form, and in an acute form it often remains negative).
• Increased concentration of sialic acids.

Have you ordered a blood lipid test? Find out what this analysis shows and how to decipher its result.

In subacute IE, bacteremia is persistent. The number of bacteria in the venous blood reaches 1-200 / ml. To detect bacteremia, venous blood must be drawn three times 16-20 ml each with an interval of 1 hour between the first and the last. When determining the pathogen, its sensitivity to antibiotics and antimycotics is revealed.

Changes in urinalysis: microhematuria - blood in the urine, proteinuria - protein in the urine, despite the absence of clinical manifestations of impairment in the kidneys. If glomerunephritis develops, then severe hematuria and proteinuria appear.

Instrumental

When conducting electrocardiography, conduction disturbances (synotrial, AV - blockade) can be detected in 4-16% of patients, which arise from focal myocarditis, myocardial abscess against the background of bacterial endocarditis. With embolic lesions of the arteries, infarction ECG changes can be detected.

Echocardiography determines vegetation (they are detected at a size of at least 4-5 mm). A more sensitive way to determine vegetation is transesophageal echocardiography. In addition to vegetation, using this method, you can notice abscesses, valve perforation, ruptures of the Valsalva sinus. The method is used to monitor the dynamics and effectiveness of treatment.

Magnetic resonance imaging and computed tomography (MRI and CT) are also performed.

All these methods allow to identify specific lesions of the heart valves and their severity.

Diagnostic criteria

There are large and small criteria for the diagnosis of infectious bacterial endocarditis that have been developed by the Duke University Endocarditis Service.

Large

Among them it is necessary to highlight:

1. Isolation of microbes typical for IE - S. bovi, HACEK, Streptococcus greens, Staphylococcus aureus, or Enterococcus in two blood samples taken separately. Microbes are also released in blood samples taken with an interval of 12 hours, or a positive result was obtained in 3 samples, which were taken with an interval between the first and the last for at least an hour.
2. Signs of endocardial involvement during echocardiography... These include:
   • oscillation of intracardiac masses on the valves, adjacent areas to them or on implanted materials, including the flow of the regurgitating blood stream;
   • annulus fibrosus abscess;
   • the emergence of a new regurgitation.

Small

These criteria include:

An accurate formulation of the diagnosis of infective endocarditis is possible if there are two large, or one large and three small criteria, or five small ones.

Probable infective endocarditis is a symptom that does not fit the “definite” category, but does not fit the “excluded” category either.

The excluded is excluded if symptoms disappear after 4 days of antibacterial therapy, there are no signs of IE during surgery, or according to information obtained during autopsy.

Treatment is carried out only in a 24-hour hospital.

Etiotropic

The basis of the treatment regimen for bacterial endocarditis is antibiotic therapy.... First, when establishing a diagnosis, broad-spectrum antibiotics are prescribed, after determining the pathogen in blood culture tests, therapy is adjusted with the appointment of the most sensitive drug. If the pathogen is not identified, then an analysis of the clinical situation is carried out with the identification of the most likely pathogen and re-seeding.

For the treatment of bacterial infective endocarditis, long-term administration of large doses of antibiotics is required. infectious processes on the valves of the heart are difficult to treat.

Pharmacotherapy of infective endocarditis caused by bacteria involves the following drugs of choice:

• antibiotics of the penicillin series;
• cephalosporins;
• fluoroquinolones;
• vancomycin;
• daptomycin.

If the causative agents of infective endocarditis are fungal in nature, antifungal drugs are prescribed... With prolonged use of antibiotics, candidiasis can develop, which also requires the appointment of antifungal therapy. It includes:

• liposomal amphotericin B (or other lipid forms) with / without flucytosine or echinocandin - with IE Candida;
• voriconazole (drug of choice), amphotericin B and echinocandin are also recommended for Aspergillus.

Sometimes suppressive treatment (fluconazole or voriconazole) for the fungal form of IE is recommended to be prescribed to the patient for life, since fungal endocarditis is more severe than other types of infective endocarditis. Most often, the basis of treatment for fungal IE is still surgical excision of the affected valves.

Glucocorticoids are also used. These are hormonal drugs, similar to human hormones, which are produced by the adrenal glands. They are used in case of weakened immunity, suspicion of a viral etiology of endocarditis and in the development of complications associated with kidney function. In addition, with the viral nature of the disease, antibiotics can be prescribed to suppress the inflammatory process.

For culture-negative infective endocarditis, the following drugs are used:

• doxycycline with cotrimoxazole and rifampicin;
• doxycycline with hydroxychloroquine;
• doxycycline with gentamicin;
• levofloxacin or clarithromycin.

And for the prevention of blood clots, drugs are prescribed that reduce blood clotting - antiplatelet agents.

Symptomatic

• Hypocoagulation: administration of heparin in combination with plasma.
• Immunomodulatory therapy: hyperimmune plasma, human immunoglobulin is used.
• Inhibition of proteolytic enzymes.
• Detoxification therapy. For example, plasmaphoresis. During which the waste products of bacteria are removed from the blood plasma. The intoxication of the body is reduced. It is used in combination with medical or surgical treatment.

Surgical

Despite the correct and adequate treatment, 1/3 of patients require surgical intervention, regardless of the activity of the infection.

Absolute indications for this are:

• an increase in heart failure, persistent persistence of symptoms, despite treatment;
• resistance to antibacterial treatment for 21 days;
• abscesses of the myocardium, fibrous valve ring;
• artificial valve endocarditis;
• fungal infections.

Relative indications are:

• repeated embolization due to destruction of vegetation;
• persistence of fever despite treatment;
• increasing the size of vegetation during treatment.

Fungal endocarditis is the most severe because he does not respond well to conservative therapy... The mainstay of his treatment is surgery with parallel administration of an antifungal antibiotic.

Consequences and complications

Bacterial or viral infective endocarditis is a rather dangerous disease, in the absence of timely qualified treatment, the transferred pathology can provoke serious complications and consequences from many organs and systems:

This is a far from complete list of possible complications, all of them are very serious and can significantly affect the patient's quality of life. therefore early diagnosis and prompt treatment are essential antibacterial drugs.

Forecasts

The prognosis of bacterial endocarditis is conditionally unfavorable... Before the introduction of broad-spectrum antibacterial drugs into practice, the disease in most cases ended in death.

Today thanks to effective treatment, mortality has decreased by up to 30%... Death can result from heart failure, kidney failure, thromboembolism, or other serious complications.

A favorable outcome is possible with early powerful antibiotic therapy in combination with comprehensive symptomatic treatment. In this case, the chances of recovery are significantly increased (with the formation of residual sclerotic changes in the valves of varying severity).

Ability to work after a disease is restored very slowly, often the patient develops irreversible changes in the valvular apparatus of the heart.

Relapses of the disease are possible if antibiotic therapy is inadequate or insufficient... In this case, surgical treatment is indicated to avoid complications. The appearance of symptoms of bacterial endocarditis 6 weeks after treatment indicates the beginning of a new infectious process.

In the absence of therapy, the acute form of the disease ends in death within 4-6 weeks. Subacute - within 6 months. Adverse signs are as follows:

• heart failure;
• non-streptococcal etiology;
• valve prosthesis infection;
• involvement of the aortic valve;
• old age of the patient;
• myocardial abscess;
• involvement of the annulus fibrosus.

Prevention measures

As for prophylactic antibiotic therapy, such drugs are used:

1. When manipulating the nasal, oral cavity, middle ear, which are accompanied by bleeding, prevention of hematogenous spread of streptococcus green is recommended. For this, amoxicillin is used in an amount of 3 g orally 60 minutes before the intervention, and also 1.5 g 6 hours after.
2. If you are allergic to penicillins, then 800 mg of erythromycin or 300 mg of clindamycin will be used 120 minutes before the procedure, and 6 hours after, 50% of the initial dose is required.
3. With urological and interventions and on the gastrointestinal tract, the prevention of enterococcal infection is carried out. For this, ampicillin is prescribed in an amount of 2 g intramuscularly or intravenously in combination with gentamicin in an amount of 1.5 mg / kg intramuscularly or intravenously, and amoxicillin in an amount of 1.5 g is prescribed orally.

Bacterial endocarditis is a serious and dangerous disease, like most heart pathologies. Therefore, in order to avoid all the consequences and complications, it is better to actively engage in prevention, seek qualified medical help in a timely manner and not self-medicate. Take care of yourself and your heart!

Learn more about bacterial infective endocarditis in this video: