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Infective endocarditis involving an apparently structurally normal valve: new epidemiological trend?

Song JK - Korean J. Intern. Med. (2015)

Bottom Line: IE involving a structurally normal valve was associated with both nosocomial and non-nosocomial HAIE, whereas community-acquired IE was more frequent than HAIE.Structurally normal valves are not necessarily free of regurgitation or abnormal turbulence and, given the dynamic nature and fluctuating hemodynamic effects of conditions such as poorly controlled hypertension, end-stage renal disease, and sleep apnea, further investigation is necessary to evaluate the potential role of these diseases in the development of IE.An apparently normal-looking valve is associated with IE development in patients without previously recognized predisposing heart disease, warranting repartition of at-risk groups to achieve better clinical outcomes.

View Article: PubMed Central - PubMed

Affiliation: Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, Korea.

ABSTRACT
Infective endocarditis (IE) has been increasingly diagnosed in patients without previously detected predisposing heart disease, but its clinical features have yet to be fully determined. A recent single-center study including echocardiographic images and surgical findings investigated the incidence of undiagnosed, clinically silent valvular or congenital heart diseases and healthcare-associated infective endocarditis (HAIE). The study confirmed that a large proportion of patients with IE have no previous history of heart disease. Analysis of underlying disease in these patients showed that undetected mitral valve prolapse was the most common disease, followed by an apparently structurally normal valve. The patients who developed IE of apparently structurally normal valves had different clinical characteristics and worse outcomes. IE involving a structurally normal valve was associated with both nosocomial and non-nosocomial HAIE, whereas community-acquired IE was more frequent than HAIE. The pathophysiologic mechanism involving the development of non-HAIE or community-acquired IE due to predominantly staphylococcal infection in an apparently structurally normal valve is not yet clearly understood. Structurally normal valves are not necessarily free of regurgitation or abnormal turbulence and, given the dynamic nature and fluctuating hemodynamic effects of conditions such as poorly controlled hypertension, end-stage renal disease, and sleep apnea, further investigation is necessary to evaluate the potential role of these diseases in the development of IE. An apparently normal-looking valve is associated with IE development in patients without previously recognized predisposing heart disease, warranting repartition of at-risk groups to achieve better clinical outcomes.

No MeSH data available.


Related in: MedlinePlus

Representative echocardiographic images of a patient with community-acquired infective endocarditis involving an apparently normal-looking valve. The patient, a 66-year-old female with poorly controlled diabetes mellitus, visited the emergency department due to fever and back pain. Blood culture showed Enterococcus faecalis bacteremia. Transthoracic echocardiographic images showed a normal-appearing mitral valve with a suspicious mass attached to the left atrial side of the mitral leaflet (A, B) and transesophageal echocardiography clearly showed a textured surface typical of vegetation (C, D; arrows). Ao, aorta; LA, left atrium; LV, left ventricle.
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Figure 4: Representative echocardiographic images of a patient with community-acquired infective endocarditis involving an apparently normal-looking valve. The patient, a 66-year-old female with poorly controlled diabetes mellitus, visited the emergency department due to fever and back pain. Blood culture showed Enterococcus faecalis bacteremia. Transthoracic echocardiographic images showed a normal-appearing mitral valve with a suspicious mass attached to the left atrial side of the mitral leaflet (A, B) and transesophageal echocardiography clearly showed a textured surface typical of vegetation (C, D; arrows). Ao, aorta; LA, left atrium; LV, left ventricle.

Mentions: Healthcare associated infective endocarditis (HAIE) is another new epidemiologic trend of IE [13141516], and IE of an apparently normal-looking valve can be associated with both nosocomial (Fig. 2) and non-nosocomial (Fig. 3) HAIE. However, a recent report found that, interestingly, community-acquired IE involving an apparently normal looking valve (Fig. 4) is more frequent than HAIE (59% vs. 41%) [11]. The increasing clinical impact of this type of IE must be considered carefully, because neglecting this increasing proportion of IE patients may negatively impact their mortality rate. Compared to IE in patients with clinically silent valvular or congenital heart disease, patients with IE of apparently normal valves tend to be older with a higher incidence of diabetes and end-stage renal disease on hemodialysis, larger vegetation size, higher European System for Cardiac Operative Risk Evaluation II (EuroSCORE II), more frequent involvement of the aortic and tricuspid valve, and higher rates of IE with staphylococcal and enterococcal infection (Table 2). Surgery was performed less frequently in these patients due to their poorer medical status, which resulted in higher mortality.


Infective endocarditis involving an apparently structurally normal valve: new epidemiological trend?

Song JK - Korean J. Intern. Med. (2015)

Representative echocardiographic images of a patient with community-acquired infective endocarditis involving an apparently normal-looking valve. The patient, a 66-year-old female with poorly controlled diabetes mellitus, visited the emergency department due to fever and back pain. Blood culture showed Enterococcus faecalis bacteremia. Transthoracic echocardiographic images showed a normal-appearing mitral valve with a suspicious mass attached to the left atrial side of the mitral leaflet (A, B) and transesophageal echocardiography clearly showed a textured surface typical of vegetation (C, D; arrows). Ao, aorta; LA, left atrium; LV, left ventricle.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4497914&req=5

Figure 4: Representative echocardiographic images of a patient with community-acquired infective endocarditis involving an apparently normal-looking valve. The patient, a 66-year-old female with poorly controlled diabetes mellitus, visited the emergency department due to fever and back pain. Blood culture showed Enterococcus faecalis bacteremia. Transthoracic echocardiographic images showed a normal-appearing mitral valve with a suspicious mass attached to the left atrial side of the mitral leaflet (A, B) and transesophageal echocardiography clearly showed a textured surface typical of vegetation (C, D; arrows). Ao, aorta; LA, left atrium; LV, left ventricle.
Mentions: Healthcare associated infective endocarditis (HAIE) is another new epidemiologic trend of IE [13141516], and IE of an apparently normal-looking valve can be associated with both nosocomial (Fig. 2) and non-nosocomial (Fig. 3) HAIE. However, a recent report found that, interestingly, community-acquired IE involving an apparently normal looking valve (Fig. 4) is more frequent than HAIE (59% vs. 41%) [11]. The increasing clinical impact of this type of IE must be considered carefully, because neglecting this increasing proportion of IE patients may negatively impact their mortality rate. Compared to IE in patients with clinically silent valvular or congenital heart disease, patients with IE of apparently normal valves tend to be older with a higher incidence of diabetes and end-stage renal disease on hemodialysis, larger vegetation size, higher European System for Cardiac Operative Risk Evaluation II (EuroSCORE II), more frequent involvement of the aortic and tricuspid valve, and higher rates of IE with staphylococcal and enterococcal infection (Table 2). Surgery was performed less frequently in these patients due to their poorer medical status, which resulted in higher mortality.

Bottom Line: IE involving a structurally normal valve was associated with both nosocomial and non-nosocomial HAIE, whereas community-acquired IE was more frequent than HAIE.Structurally normal valves are not necessarily free of regurgitation or abnormal turbulence and, given the dynamic nature and fluctuating hemodynamic effects of conditions such as poorly controlled hypertension, end-stage renal disease, and sleep apnea, further investigation is necessary to evaluate the potential role of these diseases in the development of IE.An apparently normal-looking valve is associated with IE development in patients without previously recognized predisposing heart disease, warranting repartition of at-risk groups to achieve better clinical outcomes.

View Article: PubMed Central - PubMed

Affiliation: Asan Medical Center Heart Institute, University of Ulsan College of Medicine, Seoul, Korea.

ABSTRACT
Infective endocarditis (IE) has been increasingly diagnosed in patients without previously detected predisposing heart disease, but its clinical features have yet to be fully determined. A recent single-center study including echocardiographic images and surgical findings investigated the incidence of undiagnosed, clinically silent valvular or congenital heart diseases and healthcare-associated infective endocarditis (HAIE). The study confirmed that a large proportion of patients with IE have no previous history of heart disease. Analysis of underlying disease in these patients showed that undetected mitral valve prolapse was the most common disease, followed by an apparently structurally normal valve. The patients who developed IE of apparently structurally normal valves had different clinical characteristics and worse outcomes. IE involving a structurally normal valve was associated with both nosocomial and non-nosocomial HAIE, whereas community-acquired IE was more frequent than HAIE. The pathophysiologic mechanism involving the development of non-HAIE or community-acquired IE due to predominantly staphylococcal infection in an apparently structurally normal valve is not yet clearly understood. Structurally normal valves are not necessarily free of regurgitation or abnormal turbulence and, given the dynamic nature and fluctuating hemodynamic effects of conditions such as poorly controlled hypertension, end-stage renal disease, and sleep apnea, further investigation is necessary to evaluate the potential role of these diseases in the development of IE. An apparently normal-looking valve is associated with IE development in patients without previously recognized predisposing heart disease, warranting repartition of at-risk groups to achieve better clinical outcomes.

No MeSH data available.


Related in: MedlinePlus