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Gamma camera imaging of infectious endocarditis. Nucl Med Mol Imaging 2022. [DOI: 10.1016/b978-0-12-822960-6.00085-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Alex J, Patel H, Shah R, Saba S, Zughaib M. Isolated Sub-Pulmonic Valve Endocarditis in a Patient With a History of Konno Procedure and Mechanical Aortic Valve. Cureus 2021; 13:e17594. [PMID: 34646646 PMCID: PMC8483447 DOI: 10.7759/cureus.17594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2021] [Indexed: 11/19/2022] Open
Abstract
Pulmonic and sub-pulmonic valve endocarditis are rarely encountered in clinical practice. We present the first case of isolated sub-pulmonic endocarditis. A 30-year-old man with a history of mechanical aortic valve presented to the emergency department with multiple complaints including nausea, vomiting, body aches, and fevers. The patient underwent surgical resection for sub-aortic stenosis followed by a modified Konno procedure later in life. A modified basal short-axis view on the trans-thoracic echocardiogram revealed a sub-pulmonic mobile structure highly suggestive of infective endocarditis. Blood cultures grew methicillin-sensitive Staphylococcus aureus within 24 hours. Higher oxygen demand prompted chest imaging, chest CT showed the development of bilateral airspace consolidation, suggestive of pneumonia. After treatment with extended intravenous antibiotics, follow-up echocardiogram four months later showed no identifiable sub-pulmonic vegetation. This case describes a situation where clinicians may suspect infective endocarditis in a typical location such as a mechanical aortic valve. However, in patients who develop pneumonia, infective endocarditis of the right heart should be suspected. The pulmonic valve and sub-pulmonic ridge are often difficult to image given their anatomical location, a modified basal short-axis view on trans-thoracic echocardiogram can better image these structures.
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Affiliation(s)
- Jacob Alex
- Department of Internal Medicine, Ascension Providence Hospital, Southfield, USA
| | - Harshil Patel
- Department of Cardiovascular Medicine, Ascension Providence Hospital, Southfield, USA
| | - Roshni Shah
- Department of Cardiovascular Medicine, Ascension Providence Hospital, Southfield, USA
| | - Souheil Saba
- Department of Cardiovascular Medicine, Ascension Providence Hospital, Southfield, USA
| | - Marcel Zughaib
- Department of Cardiovascular Medicine, Ascension Providence Hospital, Southfield, USA
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3
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Corey KM, Campbell MJ, Hill KD, Hornik CP, Krasuski R, Barker PC, Jaquiss RDB, Li JS. Pulmonary Valve Endocarditis: The Potential Utility of Multimodal Imaging Prior to Surgery. World J Pediatr Congenit Heart Surg 2020; 11:192-197. [PMID: 32093564 DOI: 10.1177/2150135119896287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The presence of echocardiographic (echo) evidence is a major criterion for the diagnosis of infective endocarditis (IE) by modified Duke criteria. Pulmonary valve (PV) IE, however, can be challenging to identify by echo. We sought to evaluate the added utility of multimodal imaging in PV IE. METHODS This is a single-center case series. We retrospectively analyzed demographic, laboratory, imaging, clinical, and surgical data from patients diagnosed with PV IE from 2008 to 2018. RESULTS A total of 23 patients were identified with definite PV IE by Duke criteria (83% male and ages 2 months to 70 years). Twenty-two patients had congenital heart disease, with 21 involving the right ventricular outflow tract (including three with transcatheter PV implant). Overall, 20 (87%) of 23 had positive blood cultures. A total of 17 (74%) of 23 patients demonstrated echo evidence of PV IE. In three cases, echo was negative (did not show vegetations) but showed new PV obstruction. In four cases with negative transthoracic echocardiogram and transesophageal echocardiogram, evidence of PV IE was subsequently seen by positron emission tomography/computed tomography (n = 2) or cardiac magnetic resonance imaging (n = 2). Pulmonary valve IE was confirmed at surgery by evaluation of pathologic samples in 20 cases. CONCLUSIONS Multimodal imaging improves the ability to preoperatively identify endocardial involvement in PV IE in cases where echo is negative. Consideration should be given to revise Duke criteria to include new obstruction and endocardial involvement by multimodal imaging for PV IE.
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Affiliation(s)
| | | | - Kevin D Hill
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Christoph P Hornik
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Richard Krasuski
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Piers C Barker
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Robert D B Jaquiss
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Jennifer S Li
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
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Abdelghani M, Nassif M, Blom NA, Van Mourik MS, Straver B, Koolbergen DR, Kluin J, Tijssen JG, Mulder BJM, Bouma BJ, de Winter RJ. Infective Endocarditis After Melody Valve Implantation in the Pulmonary Position: A Systematic Review. J Am Heart Assoc 2018; 7:JAHA.117.008163. [PMID: 29934419 PMCID: PMC6064882 DOI: 10.1161/jaha.117.008163] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Infective endocarditis (IE) after transcatheter pulmonary valve implantation (TPVI) in dysfunctioning right ventricular outflow tract conduits has evoked growing concerns. We aimed to investigate the incidence and the natural history of IE after TPVI with the Melody valve through a systematic review of published data. Methods and Results PubMed, EMBASE, and Web of Science databases were systematically searched for articles published until March 2017, reporting on IE after TPVI with the Melody valve. Nine studies (including 851 patients and 2060 patient‐years of follow‐up) were included in the analysis of the incidence of IE. The cumulative incidence of IE ranged from 3.2% to 25.0%, whereas the annualized incidence rate ranged from 1.3% to 9.1% per patient‐year. The median (interquartile range) time from TPVI to the onset of IE was 18.0 (9.0–30.4) months (range, 1.0–72.0 months). The most common findings were positive blood culture (93%), fever (89%), and new, significant, and/or progressive right ventricular outflow tract obstruction (79%); vegetations were detectable on echocardiography in only 34% of cases. Of 69 patients with IE after TPVI, 6 (8.7%) died and 35 (52%) underwent surgical and/or transcatheter reintervention. Death or reintervention was more common in patients with new/significant right ventricular outflow tract obstruction (69% versus 33%; P=0.042) and in patients with non‐streptococcal IE (73% versus 30%; P=0.001). Conclusions The incidence of IE after implantation of a Melody valve is significant, at least over the first 3 years after TPVI, and varies considerably between the studies. Although surgical/percutaneous reintervention is a common consequence, some patients can be managed medically, especially those with streptococcal infection and no right ventricular outflow tract obstruction.
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Affiliation(s)
- Mohammad Abdelghani
- Department of Cardiology, Academic Medical Center, University of Amsterdam, the Netherlands
| | - Martina Nassif
- Department of Cardiology, Academic Medical Center, University of Amsterdam, the Netherlands
| | - Nico A Blom
- Department of Cardiology, Academic Medical Center, University of Amsterdam, the Netherlands.,Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Martijn S Van Mourik
- Department of Cardiology, Academic Medical Center, University of Amsterdam, the Netherlands
| | - Bart Straver
- Department of Pediatric Cardiology, Academic Medical Center, University of Amsterdam, the Netherlands
| | - David R Koolbergen
- Department of Cardiothoracic Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - Jolanda Kluin
- Department of Cardiothoracic Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - Jan G Tijssen
- Department of Cardiology, Academic Medical Center, University of Amsterdam, the Netherlands
| | - Barbara J M Mulder
- Department of Cardiology, Academic Medical Center, University of Amsterdam, the Netherlands.,Interuniversity Cardiology Institute of the Netherlands, Utrecht, the Netherlands
| | - Berto J Bouma
- Department of Cardiology, Academic Medical Center, University of Amsterdam, the Netherlands
| | - Robbert J de Winter
- Department of Cardiology, Academic Medical Center, University of Amsterdam, the Netherlands
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5
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Right ventricular outflow tract endocarditis caused by brucellosis. J Infect Public Health 2017; 10:678-680. [DOI: 10.1016/j.jiph.2016.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 08/23/2016] [Accepted: 09/10/2016] [Indexed: 11/22/2022] Open
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Miranda WR, Connolly HM, DeSimone DC, Phillips SD, Wilson WR, Sohail MR, Steckelberg JM, Baddour LM. Infective Endocarditis Involving the Pulmonary Valve. Am J Cardiol 2015; 116:1928-31. [PMID: 26611123 DOI: 10.1016/j.amjcard.2015.09.038] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 09/06/2015] [Accepted: 09/06/2015] [Indexed: 01/09/2023]
Abstract
Pulmonary valve (PV) infective endocarditis (IE) is a rare entity, accounting for 1.5% to 2% of cases of IE. Published data are limited to a few case series and reports. We sought to review the Mayo Clinic experience and describe clinical, echocardiographic, and microbiologic features. We included all patients aged ≥18 years seen from 2000 to 2014 who had a diagnosis of native PV IE and unequivocal echocardiographic involvement of the PV. Nine patients with PV IE were identified. Isolated PV IE was present in 7 (78%) of 9 cases. The median age was 59 years and 22% were women. Three patients had congenital heart disease, 2 had central venous catheters, and 3 had cardiovascular implantable electronic devices. Five patients (56%) received chronic immunosuppressive therapy. Enterococcus faecalis and viridans group streptococci were the most common pathogens, isolated in 22% of cases each. Transthoracic echocardiogram (TTE) and transesophageal echocardiogram (TEE) were done in 6 and 7 patients, respectively. Four patients underwent both procedures. TTE was diagnostic in all cases, but TEE failed to detect PV involvement in 1 patient. Median follow-up was 1.8 years. Five patients (56%) underwent PV replacement. There were no operative deaths. One patient had sudden death during follow-up, unrelated to his PV IE episode. Our results suggest that PV IE is rare but carries significant morbidity. TTE and TEE provide complementary information with TEE providing better visualization of other cardiac structures. Our findings of a high prevalence of immunosuppressive therapy and cardiovascular implantable electronic devices have not been previously reported and deserve further investigation.
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Vilacosta I, Olmos C, de Agustín A, López J, Islas F, Sarriá C, Ferrera C, Ortiz-Bautista C, Sánchez-Enrique C, Vivas D, San Román A. The diagnostic ability of echocardiography for infective endocarditis and its associated complications. Expert Rev Cardiovasc Ther 2015; 13:1225-36. [PMID: 26471429 DOI: 10.1586/14779072.2015.1096780] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Echocardiography, transthoracic and transoesophageal, plays a key role in the diagnosis and prognosis assessment of patients with infective endocarditis. It constitutes a major Duke criterion and is pivotal in treatment guiding. Seven echocardiographic findings are major criteria in the diagnosis of infective endocarditis (IE) (vegetation, abscess, pseudoaneurysm, fistulae, new dehiscence of a prosthetic valve, perforation and valve aneurysm). Echocardiography must be performed as soon as endocarditis is suspected. Transoesophageal echocardiography should be done in most cases of left-sided endocarditis to better define the anatomic lesions and to rule out local complications. Transoesophageal echocardiography is not necessary in isolated right-sided native valve IE with good quality transthoracic examination and unequivocal echocardiographic findings. Echocardiography is a very useful tool to assess the prognosis of patients with IE at any time during the course of the disease. Echocardiographic predictors of poor outcome include presence of periannular complications, prosthetic dysfunction, low left ventricular ejection fraction, pulmonary hypertension and very large vegetations.
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Affiliation(s)
- Isidre Vilacosta
- a 1 Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain
| | - Carmen Olmos
- a 1 Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain
| | - Alberto de Agustín
- a 1 Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain
| | - Javier López
- b 2 Instituto de Ciencias del Corazón (ICICOR), Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Fabián Islas
- a 1 Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain
| | - Cristina Sarriá
- c 3 Servicio de Medicina Interna-Infecciosas, Instituto de Investigación Sanitaria del Hospital Universitario de la Princesa, Madrid, Spain
| | - Carlos Ferrera
- a 1 Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain
| | - Carlos Ortiz-Bautista
- b 2 Instituto de Ciencias del Corazón (ICICOR), Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | | | - David Vivas
- a 1 Instituto Cardiovascular, Hospital Clínico San Carlos, Madrid, Spain
| | - Alberto San Román
- b 2 Instituto de Ciencias del Corazón (ICICOR), Hospital Clínico Universitario de Valladolid, Valladolid, Spain
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Habib G, Lancellotti P, Antunes MJ, Bongiorni MG, Casalta JP, Del Zotti F, Dulgheru R, El Khoury G, Erba PA, Iung B, Miro JM, Mulder BJ, Plonska-Gosciniak E, Price S, Roos-Hesselink J, Snygg-Martin U, Thuny F, Tornos Mas P, Vilacosta I, Zamorano JL. 2015 ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J 2015; 36:3075-3128. [PMID: 26320109 DOI: 10.1093/eurheartj/ehv319] [Citation(s) in RCA: 3096] [Impact Index Per Article: 344.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
MESH Headings
- Acute Kidney Injury/diagnosis
- Acute Kidney Injury/therapy
- Ambulatory Care
- Aneurysm, Infected/diagnosis
- Aneurysm, Infected/therapy
- Anti-Bacterial Agents/therapeutic use
- Antibiotic Prophylaxis
- Arrhythmias, Cardiac/diagnosis
- Arrhythmias, Cardiac/therapy
- Clinical Laboratory Techniques
- Critical Care
- Cross Infection/etiology
- Dentistry, Operative
- Diagnostic Imaging/methods
- Embolism/diagnosis
- Embolism/therapy
- Endocarditis/diagnosis
- Endocarditis/therapy
- Endocarditis, Non-Infective/diagnosis
- Endocarditis, Non-Infective/therapy
- Female
- Fibrinolytic Agents/therapeutic use
- Heart Defects, Congenital
- Heart Failure/diagnosis
- Heart Failure/therapy
- Heart Valve Diseases/diagnosis
- Heart Valve Diseases/therapy
- Humans
- Long-Term Care
- Microbiological Techniques
- Musculoskeletal Diseases/diagnosis
- Musculoskeletal Diseases/microbiology
- Musculoskeletal Diseases/therapy
- Myocarditis/diagnosis
- Myocarditis/therapy
- Neoplasms/complications
- Nervous System Diseases/diagnosis
- Nervous System Diseases/microbiology
- Nervous System Diseases/therapy
- Patient Care Team
- Pericarditis/diagnosis
- Pericarditis/therapy
- Postoperative Complications/etiology
- Postoperative Complications/prevention & control
- Pregnancy
- Pregnancy Complications, Cardiovascular/diagnosis
- Pregnancy Complications, Cardiovascular/therapy
- Prognosis
- Prosthesis-Related Infections/diagnosis
- Prosthesis-Related Infections/therapy
- Recurrence
- Risk Assessment
- Risk Factors
- Splenic Diseases/diagnosis
- Splenic Diseases/therapy
- Thoracic Surgical Procedures
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Xie J, Liu S, Yang J, Xu J, Zhu G. Inaccuracy of transthoracic echocardiography for the identification of right‐sided vegetation in patients with no history of intravenous drug abuse or cardiac device insertion. J Int Med Res 2014; 42:837-48. [PMID: 24717408 DOI: 10.1177/0300060513505498] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Accepted: 08/28/2013] [Indexed: 11/16/2022] Open
Abstract
Objective: The use of transthoracic echocardiography (TTE) to identify right-sided infective endocarditis (RSIE) vegetation is controversial. Data are scarce for patients with no history of intravenous drug abuse (IVDA) or cardiac device insertion. This study analysed the consistency of presurgical echocardiographic results with surgical findings for vegetation identification, and the factors that influence accuracy of echocardiography. Methods: This retrospective trial divided infective endocarditis (IE) patients into three subgroups according to the results of their presurgical TTE: left-sided native IE (LSNIE), left-sided prosthetic valve IE (LSPIE) and RSIE. The accuracy of TTE was tested by comparing vegetation (number and location), detected presurgery by TTE, with actual findings during surgery. Results: In total, 416 patients were analysed, 322 with LSNIE, 31 with LSPIE and 63 with RSIE. Consistency between TTE findings and surgical results was lower in the RSIE group compared with the LSPIE and LSNIE groups. Consistency was lowered by the presence of vegetation in multiple locations and atypical distribution – both of which were increased in the RSIE group. The chance of vegetation in both sides of the heart rose with increased numbers of vegetation locations in RSIE patients. A high proportion of RSIE patients had congenital heart defects, mostly ventricular septal defects. Conclusions: TTE may be unsuitable for RSIE patients with no history of IVDA or cardiac device insertion, because multifocal and atypically distributed vegetation may influence detection accuracy.
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Affiliation(s)
- Jiang Xie
- Pulmonary Heart Centre, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Shuang Liu
- Pulmonary Heart Centre, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jinghua Yang
- Pulmonary Heart Centre, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jie Xu
- Pulmonary Heart Centre, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Guangfa Zhu
- Pulmonary Heart Centre, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Akinosoglou K, Apostolakis E, Marangos M, Pasvol G. Native valve right sided infective endocarditis. Eur J Intern Med 2013; 24:510-9. [PMID: 23369408 DOI: 10.1016/j.ejim.2013.01.010] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Revised: 12/23/2012] [Accepted: 01/04/2013] [Indexed: 11/25/2022]
Abstract
Right-sided infective endocarditis (RSIE) accounts for 5-10% of all cases of infective endocarditis (IE), and is predominantly encountered in the injecting drug user (IDU) population, where HIV and HCV coinfections often coexist. Staphylococcus aureus is the most common pathogen. The pathogenesis of RSIE is still not well understood. RSIE usually presents as a persistent fever with respiratory symptoms whilst signs of systemic embolisation as seen in left-sided IE are notably absent. The prompt diagnosis of RSIE thus requires a high index of suspicion. Transthoracic echocardiography (TTE) can detect the majority of RSIE, whilst transoesophageal echocardiography (TOE) can increase sensitivity. Virulence of the causative organism and vegetation size are the major determinants of prognosis. Most cases of RSIE resolve with appropriate antibiotic administration.
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Affiliation(s)
- Karolina Akinosoglou
- Department of Internal Medicine and Infectious Diseases, University Hospital of Patras, 26504, Rio, Greece.
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11
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Role of transthoracic and transesophageal echocardiography in right-sided endocarditis: one echocardiographic modality does not fit all. J Am Soc Echocardiogr 2012; 25:807-14. [PMID: 22727494 DOI: 10.1016/j.echo.2012.05.016] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Indexed: 12/12/2022]
Abstract
The added value of transesophageal echocardiography (TEE) over transthoracic echocardiography in the assessment of left-sided infective endocarditis has been extensively validated in the literature. Little research has dealt with the role of echocardiography in right-sided infective endocarditis (RSE), however. In this review, the differences between RSE and left-sided endocarditis and the different types of RSE according to the types of patients who have the disease are described. Both issues have important implications for echocardiographic workup. Moreover, a systematic echocardiographic protocol to avoid missing right-sided vegetations and several specific morphologic aspects of RSE are reviewed. Normal right-sided structures, which may mimic vegetations, particularly when the clinical picture is compatible, are described. Finally, the value of transthoracic echocardiography and TEE in RSE is reviewed according to the publications available. The diagnostic yield of transthoracic echocardiography is comparable with that of TEE in intravenous drug users. On the contrary, TEE is mandatory in patients with cardiac devices. A Bayesian-based diagnostic approach is proposed for a third poorly characterized group of patients with RSE who are not drug addicts, have no cardiac devices, and have no left-sided endocarditis (the "three no's" endocarditis group).
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13
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Habib G, Hoen B, Tornos P, Thuny F, Prendergast B, Vilacosta I, Moreillon P, de Jesus Antunes M, Thilen U, Lekakis J, Lengyel M, Müller L, Naber CK, Nihoyannopoulos P, Moritz A, Luis Zamorano J. Guía de práctica clínica para prevención, diagnóstico y tratamiento de la endocarditis infecciosa (nueva versión 2009). Rev Esp Cardiol 2009. [DOI: 10.1016/s0300-8932(09)73131-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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14
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Habib G, Hoen B, Tornos P, Thuny F, Prendergast B, Vilacosta I, Moreillon P, de Jesus Antunes M, Thilen U, Lekakis J, Lengyel M, Müller L, Naber CK, Nihoyannopoulos P, Moritz A, Zamorano JL, Vahanian A, Auricchio A, Bax J, Ceconi C, Dean V, Filippatos G, Funck-Brentano C, Hobbs R, Kearney P, McDonagh T, McGregor K, Popescu BA, Reiner Z, Sechtem U, Sirnes PA, Tendera M, Vardas P, Widimsky P, Vahanian A, Aguilar R, Bongiorni MG, Borger M, Butchart E, Danchin N, Delahaye F, Erbel R, Franzen D, Gould K, Hall R, Hassager C, Kjeldsen K, McManus R, Miro JM, Mokracek A, Rosenhek R, San Roman Calvar JA, Seferovic P, Selton-Suty C, Uva MS, Trinchero R, van Camp G. Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009): the Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and the International Society of Chemotherapy (ISC) for Infection and Cancer. Eur Heart J 2009; 30:2369-413. [PMID: 19713420 DOI: 10.1093/eurheartj/ehp285] [Citation(s) in RCA: 1227] [Impact Index Per Article: 81.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Gilbert Habib
- Service de Cardiologie, CHU La Timone, Bd Jean Moulin, 13005 Marseille, France.
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Zakja E, Badano LP, Ventruto P, Nucifora G, Gianfagna P, Fioretti PM. Pulmonary embolism and fever: an indication for urgent echocardiography not reported in clinical guidelines? J Cardiovasc Med (Hagerstown) 2007; 8:846-9. [PMID: 17885525 DOI: 10.2459/jcm.0b013e3280110599] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report the case of a 39-year-old woman who developed worsening dyspnea and abdominal pain 4 days after subtotal gastroresection. She underwent thoracic computed tomography scan and lung scintigraphy and was diagnosed with pulmonary embolism. Despite the fact that she was feverish, she was treated by the insertion of a vena cava filter and transferred to our Emergency Department. Twelve hours later, a beta-haemolytic Streptococcus agalactiae was reported to be growing in both bottles of blood cultures that had been taken. The patient underwent transthoracic two- and three-dimensional echocardiography, which showed a large pulmonary valve vegetation prolapsing into the main and right pulmonary artery during systole.
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Affiliation(s)
- Edlira Zakja
- Department of Cardiopulmonary Sciences, A. O. Santa Maria della Misericordia, Udine, Italy
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16
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Cosson S, Kevorkian JP, Milliez P, Beaufils P, Cohen A. A rare localization in right-sided endocarditis diagnosed by echocardiography: a case report. Cardiovasc Ultrasound 2003; 1:10. [PMID: 12952545 PMCID: PMC194433 DOI: 10.1186/1476-7120-1-10] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2003] [Accepted: 08/14/2003] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Right-sided endocarditis occurs predominantly in intravenous drug users, patients with pacemakers or central venous lines and with congenital heart diseases. The vast majority of cases involve the tricuspid valve. CASE PRESENTATION A case of a 31-year-old woman with intravenous drug abuse who had a right-sided vegetation attached to the muscular bundle of the right ventricle is presented. Transthoracic echocardiography revealed a vegetation in the right ventricular outflow tract. Transesophageal echocardiography clearly showed that the 1.8 cm vegetation was not adherent to the pulmonary valve but attached to a muscular bundle. CONCLUSIONS Our case points to an unusual location of right-sided endocarditis in intravenous drug users. It confirms that TTE remains an easy and highly sensitive first-line examination for the diagnosis of right-sided endocarditis.
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Affiliation(s)
- Stéphane Cosson
- Service de cardiologie, Hôpital Lariboisière, Paris and Service de cardiologie, Hôpital Saint-Antoine, Paris, France
| | - Jean-Philippe Kevorkian
- Service de cardiologie, Hôpital Lariboisière, Paris and Service de cardiologie, Hôpital Saint-Antoine, Paris, France
| | - Paul Milliez
- Service de cardiologie, Hôpital Lariboisière, Paris and Service de cardiologie, Hôpital Saint-Antoine, Paris, France
| | - Philippe Beaufils
- Service de cardiologie, Hôpital Lariboisière, Paris and Service de cardiologie, Hôpital Saint-Antoine, Paris, France
| | - Ariel Cohen
- Service de cardiologie, Hôpital Lariboisière, Paris and Service de cardiologie, Hôpital Saint-Antoine, Paris, France
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Abstract
Pulmonic valve endocarditis is an extremely rare infection that shares epidemiologic, clinical, radiologic, microbiologic, and prognostic features with tricuspid valve endocarditis. We report a case of pulmonic valve infection on a structurally normal heart and review the English-language literature on this subject.
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Affiliation(s)
- Muhammad Tariq
- Department of Medicine, Aga Khan University Medical College, Karachi, Pakistan.
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18
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Abstract
Infective endocarditis is a life-threatening disease with significant morbidity and mortality. Accurate and early diagnosis for initiation of effective treatment is essential in improving patient outcome. Echocardiography is currently the primary modality for the detection of vegetations and cardiac complications that result from endocarditis. Technological advances in echocardiography, particularly the development of transesophageal echocardiography (TEE), have revolutionized the diagnosis and management of infective endocarditis. With the enhanced resolution provided by TEE, vegetations and paravalvular complications can be reliably detected. Transthoracic and transesophageal echocardiography provides complementary information for patient management and follow-up, and is best used in conjunction with clinical data. By means of its high sensitivity and negative predictive value, TEE is essential in the evaluation of prosthetic valve endocarditis and the paravalvular complications of IE. All patients with suspected infective endocarditis should undergo transthoracic echocardiography, and most of these patients should also undergo TEE evaluation. The role of new technology such as harmonic and three-dimensional imaging is yet to be determined.
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Affiliation(s)
- Sonia Jacob
- Baylor College of Medicine, Houston, Texas, USA
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19
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20
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Akram M, Khan IA. Isolated pulmonic valve endocarditis caused by group B streprococcus (Streptococcus agalactiae)--a case report and literature review. Angiology 2001; 52:211-5. [PMID: 11269786 DOI: 10.1177/000331970105200309] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The pulmonic valve is the least commonly involved valve in infective endocarditis. Pulmonic valve endocarditis is usually associated with tricuspid valve endocarditis, and isolated pulmonic valve endocarditis is exceedingly rare. The predisposing factors for developing pulmonic valve endocarditis include a congenitally anomalous pulmonic valve, intravenous drug abuse, and the presence of indwelling intravenous or flow-directed pulmonary artery catheters. More cases of group B streptococcus endocarditis are being reported. The risk factors for group B streptococcus endocarditis include diabetes mellitus, cancer, alcoholism, malnutrition, immunocompromised status, intravenous drug abuse, postpartum and postabortion states, and underlying valvular disease. The vegetations of this type of endocarditis are usually large and have a higher tendency to result in embolism. The presentation of group B streptococcus endocarditis is usually acute and may result in rapid valve destruction if not treated promptly. A case of isolated pulmonic valve endocarditis caused by group B streptococcus, Streptococcus agalactiae, is presented that was diagnosed with multiplane transesophageal echocardiography in a 40-year old, alcoholic, malnourished man, who was successfully treated with intravenous penicillin G. The literature on the isolated pulmonic valve endocarditis caused by group B streptococcus is reviewed.
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Affiliation(s)
- M Akram
- Department of Medicine, Creighton University School of Medicine, Omaha, NE, USA
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21
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Shively BK. Transesophageal echocardiographic (TEE) evaluation of the aortic valve, left ventricular outflow tract, and pulmonic valve. Cardiol Clin 2000; 18:711-29. [PMID: 11236162 DOI: 10.1016/s0733-8651(05)70176-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The most important role of TEE in aortic valve disease is in the diagnosis of endocarditis and its complications. Examination of the annulus and subvalvular region is essential in any patient with possible aortic valve endocarditis. Assessment of the severity of aortic stenosis is a useful application of TEE when other data are either inconsistent or unavailable. TEE can provide a diagnosis of the origin of acute severe aortic insufficiency; this information may play a critical role in surgical planning. The diagnosis of a variety of aortic valve diseases can be made when TEE is performed to find an embolic source or to rule out dissection. In the case of mass lesions, such as papillary fibroelastomas and Libman-Sacks vegetations, the results of TEE carry major therapeutic implications. TEE offers generally excellent quality images of the LVOT and images of the RVOT and pulmonic valve that are superior to transthoracic echocardiography. The major clinical usefulness of TEE stems from its ability to identify pulmonic valve mass lesions and the causes of left and right ventricular outflow obstruction. TEE is also an important adjunct in the surgical management of left ventricular outflow obstruction.
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Affiliation(s)
- B K Shively
- Adult Echocardiographic Laboratory, Division of Cardiology, Oregon Health Sciences University, Portland, Oregon, USA
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22
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Seubert CN, Lobato EB, Davies LK. Presence of an echogenic mass on the pulmonary valve and right ventricular outflow tract. J Cardiothorac Vasc Anesth 1999; 13:789-90. [PMID: 10622667 DOI: 10.1016/s1053-0770(99)90138-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- C N Seubert
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville 32610-0254, USA
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23
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Abstract
This article presents an overview of the benefits and efficacy of transesophageal echocardiography (TEE) in the critically ill patient. The echocardiographic evaluation of ventricular function both regional and global, is discussed with special emphasis on ischemic heart disease; assessment of preload, interrogation of valvular heart disease (prosthetic and native) and its complications; endocarditis and its complications; intracardiac and extracardiac masses, including pulmonary embolism; aortic diseases (e.g., aneurysan, dissection, and traumatic tears); evaluation of patent foramen ovale and its association with central and peripheral embolic events; advancements in computer technology; and finally, the effect of TEE on critical care.
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Affiliation(s)
- D T Porembka
- Department of Anesthesia, University of Cincinnati College of Medicińe, Ohio, USA
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24
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Krivokapich J, Child JS. Role of transthoracic and transesophageal echocardiography in diagnosis and management of infective endocarditis. Cardiol Clin 1996; 14:363-82. [PMID: 8853131 DOI: 10.1016/s0733-8651(05)70290-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Echocardiography has become a mainstay in the diagnosis of endocarditis. Vegetations were first visualized noninvasively beginning with M-mode echocardiography in the mid-1970s. The evolution of echocardiography, to include first two-dimensional imaging and then Doppler imaging in the 1980s, established echocardiography as the noninvasive test of choice to evaluate for the presence of vegetations as well as for their sequelae. Most recently, the addition of transesophageal echocardiography has expanded the role and yield of echocardiography in diagnosing endocarditis as well as in guiding management.
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Affiliation(s)
- J Krivokapich
- Department of Medicine, University of California Los Angeles School of Medicine, USA
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25
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Shanewise JS, Martin RP. Assessment of endocarditis and associated complications with transesophageal echocardiography. Crit Care Clin 1996; 12:411-27. [PMID: 8860847 DOI: 10.1016/s0749-0704(05)70253-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
TEE offers many benefits in the evaluation of patients with IE. It provides increased sensitivity as compared to TTE in the detection of this disease, and is better able to identify and delineate many of the associated complications and hemodynamic aberrancies. TEE also has helped expand our knowledge of the pathophysiology and natural history of IE. Continued advances in the technology of TEE instrumentation undoubtedly will lead to further improvements in our ability to assess and to treat patients stricken with this serious infection. Nevertheless, IE continues to exact a significant toll on its victims, and our efforts to diagnose, to treat, and to prevent it must not weaken.
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Affiliation(s)
- J S Shanewise
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia, USA
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26
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Hutchison SJ, Rosin BL, Curry S, Chandraratna PAN. Transesophageal Echocardiographic Assessment of Lesions of the Right Ventricular Outflow Tract and Pulmonic Valve. Echocardiography 1996; 13:21-34. [PMID: 11442900 DOI: 10.1111/j.1540-8175.1996.tb00864.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
To establish the role of biplane transesophageal echocardiography (TEE) in the assessment of congenital and acquired lesions involving the right ventricular outflow tract (RVOT) and pulmonic valve (PV), 28 consecutive RVOT and PV lesions in 22 consecutive patients were studied by two-dimensional and color Doppler transthoracic echocardiograms (n = 22), horizontal (n = 22) and vertical (n = 22) plane TEEs, cardiac catheterization (n = 15), cardiac surgery (n = 6), and magnetic resonance imaging (n = 1). Sixteen patients had congenital lesions, and six had acquired lesions. Longitudinal TEE clearly imaged 25 of 28 abnormalities, transverse TEE clearly imaged 12 of 28, and transthoracic echocardiography clearly imaged 9 of 28. Two-dimensional TEE scanning revealed the lesion or site of stenosis. Color Doppler revealed conspicuous mosaic jets in relation to a structural abnormality in most cases. Longitudinal TEE was more sensitive in the detection of small vegetations of the PV, in the depiction of PV doming in cases of valvar pulmonic stenosis, and in the display of the RVOT and PV so that the longitudinal extent of involvement of larger masses could be appreciated. However, longitudinal TEE was not able to assess the gradient of a stenosis at the RVOT or PV level in any case. Biplane TEE is helpful in the anatomic assessment of congenital and acquired lesions of the RVOT and PV in adults. (ECHOCARDIOGRAPHY, Volume 13, January 1996)
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Affiliation(s)
- Stuart J. Hutchison
- Division of Cardiology, LAC/USC School of Medicine, 2025 Zonal Avenue, Room 7621, Los Angeles, CA 90033
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27
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Liu F, Ge J, Kupferwasser I, Meyer J, Mohr-Kahaly S, Rohmann S, Erbel R. Has transesophageal echocardiography changed the approach to patients with suspected or known infective endocarditis? Echocardiography 1995; 12:637-50. [PMID: 10158101 DOI: 10.1111/j.1540-8175.1995.tb00857.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Infective endocarditis is still a great clinical challenge. Its diagnosis is difficult to establish, and mortality has remained around 30%. Early diagnosis and optimal treatment are crucial fo prognosis improvement. Echocardiography plays an indispensable role in the management of this disease, especially with the recently introduced approach, transesophageal echocardiography (TEE). TEE can overcome the limitations of transthoracic echocardiography (TTE) and is superior to TTE in almost every way in providing earlier and more information for the diagnosis and treatment of infective endocarditis. TEE detects valve vegetations with much higher sensitivity and specificity than TTE. It can demonstrate smaller vegetations in the early stage of the disease and vegetations on atypical locations (e.g., mitral valve annulus), and provides detailed characterization of vegetations (e.g., location, size, mobility, and changes during treatment). Such information is of great prognostic value and may help in selecting proper treatment. TEE is more sensitive for detecting complications, such as mitral valve perforation, abscess, and subaortic complications, which respond poorly to medicine and for which timely surgery may be the best treatment. For those with prosthetic valve endocarditis, TEE is especially useful because TTE is greatly limited by the acoustic shadow of prostheses. Both positive and negative results of TEE examination are valuable for confirming or excluding infective endocarditis. TEE also plays a unique role in intraoperative monitoring and can assess surgical results before the chest is closed. TEE has become an invaluable tool for the diagnosis and management of patients with suspected or known infective endocarditis.
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Affiliation(s)
- F Liu
- Department of Cardiology, University Essen, Germany
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28
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Abstract
When infective endocarditis is a diagnostic possibility, echocardiography permits noninvasive imaging of cardiac structures. As involvement of the endocardium is a sine qua non of endocarditis, echocardiography may assist in its diagnosis by demonstrating such involvement. The ability of echocardiography to detect the intracardiac manifestations of infective endocarditis has continued to improve, especially with the introduction of transesophageal imaging. This article will discuss some of the echocardiographic findings in endocarditis and elucidate the incorporation of these findings in the new Duke criteria for the diagnosis of endocarditis.
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Affiliation(s)
- G A Dodds
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
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29
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Affiliation(s)
- W G Daniel
- Department of Medicine, University Clinic, Dresden, Germany
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30
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Puleo JA, Shammas NW, Kelly P, Allen M. Lactobacillus isolated pulmonic valve endocarditis with ventricular septal defect detected by transesophageal echocardiography. Am Heart J 1994; 128:1248-50. [PMID: 7985611 DOI: 10.1016/0002-8703(94)90761-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- J A Puleo
- Department of Internal Medicine, University of South Florida, Tampa
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31
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Cherukuri AK, Maloney M, O'Briain DS, Weir DG. Isolated pulmonary valve endocarditis: a rare or an underdiagnosed disease? Ir J Med Sci 1994; 163:494-5. [PMID: 7806440 DOI: 10.1007/bf02967092] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
A 48 year old patient with resistant coeliac disease developed prolonged unexplained pyrexia after surgery for small bowel volvulus. Despite extensive investigations and intensive antibiotic therapy, he deteriorated and died eight weeks postoperatively and significant isolated pulmonary valve endocarditis was discovered at autopsy. This diagnosis should be considered in all critically ill patients with unexplained pyrexia even in the absence of clinical features of endocarditis and transoesophageal echocardiography performed to exclude or confirm this lesion.
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Affiliation(s)
- A K Cherukuri
- University Department of Medicine and Histopathology, Trinity College, Dublin
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32
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Yvorchuk KJ, Chan KL. Application of transthoracic and transesophageal echocardiography in the diagnosis and management of infective endocarditis. J Am Soc Echocardiogr 1994; 7:294-308. [PMID: 8060646 DOI: 10.1016/s0894-7317(14)80400-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Infective endocarditis continues to be a cause of significant cardiac morbidity and mortality. To improve the prognosis of patients with this disorder, early diagnosis is crucial but difficult to establish on the basis of clinical parameters alone. Echocardiography, both transthoracic and transesophageal techniques, has a major role in the detection of vegetations that are the hallmark of endocarditis. Valvular and perivalvular complications can also be well assessed by echocardiography. With the improved resolution provided by recent technologic advances in echocardiography, vegetations can be reliably detected in most patients with endocarditis. We propose that present diagnostic criteria for endocarditis be revised to include echocardiographic findings as a major parameter in the diagnosis. Finally, a diagnostic approach incorporating transthoracic and transesophageal echocardiography in these patients will be discussed taking into consideration the different degrees of clinical suspicion for the existence of the disease.
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Affiliation(s)
- K J Yvorchuk
- University of Ottawa Heart Institute, Ontario, Canada
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33
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GUARNERI ERMINIA, TUNICK PAULA, KENNEDY JAMEST, KRONZON ITZHAK. Horizontal Plane Transesophageal Echocardiography May Be False Negative for Large Tricuspid Vegetations. Echocardiography 1994. [DOI: 10.1111/j.1540-8175.1994.tb01043.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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34
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Mügge A. ECHOCARDIOGRAPHIC DETECTION OF CARDIAC VALVE VEGETATIONS AND PROGNOSTIC IMPLICATIONS. Infect Dis Clin North Am 1993. [DOI: 10.1016/s0891-5520(20)30564-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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35
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Mulhern KM, Skorton DJ. Echocardiographic evaluation of isolated pulmonary valve disease in adolescents and adults. Echocardiography 1993; 10:533-43. [PMID: 10146329 DOI: 10.1111/j.1540-8175.1993.tb00068.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Congenital pulmonary valve disease is often not discovered until adolescence or adulthood. Transthoracic two-dimensional echocardiography can provide detailed information regarding right ventricular outflow anatomy, although images are often less satisfactory than those obtained in infants and children. The more recent addition of biplanar transesophageal echocardiography has enhanced our ability to image the right ventricular outflow tract, pulmonary valve, and pulmonary artery noninvasively. Pulsed and continuous-wave Doppler estimates of subvalvular and transvalvular gradients have proved to be accurate. Doppler color flow mapping has proved useful in determining the location and direction of stenotic and regurgitant flow. With no accepted standard for comparison, quantification of regurgitation remains problematic. In many cases, echocardiography has replaced catheterization and angiography in the evaluation and long-term follow-up of congenital pulmonary valve disease before and after intervention.
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Affiliation(s)
- K M Mulhern
- Department of Medicine, Cardiovascular Division, University of Iowa College of Medicine, Iowa City 52242
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36
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Chazouilleres AF, Foster E, Redberg RF, Schiller NB. Right ventricular outflow tract obstruction: augmented diagnosis with biplane transesophageal echocardiography. Am Heart J 1993; 126:477-80. [PMID: 8338030 DOI: 10.1016/0002-8703(93)91079-t] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- A F Chazouilleres
- Department of Medicine, University of California, San Francisco 94143
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37
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