BEDSIDE ECHO TO DIAGNOSE NATIVE VALVE INFECTIVE ENDOCARDITIS - A CASE SERIES

Dr Jonathan Henry

FACEM, GDipClinUS (University of Melbourne), CCPU (ASUM)

Twitter: @DrJonoHenry @EmergencyEcho

Facebook: www.facebook.com/EmergencyEcho


Post Peer-Reviewed by Dr Gillian Whalley, Professor of Clinical Sonography/Cardiology, University of Otago, New Zealand

Twitter: @GWhalleyPhD




Bedside echo demonstrated anterior and posterior mitral valve leaflets (AMVL/PMVL), thickened by heavy vegetations. His PMVL was prolapsing, with severe mitral regurgitation (MR) causing acute pulmonary oedema.


He was urgently transferred to a cardiothoracic unit and stabilised. His comprehensive echo showed severe MR and moderate-sized mitral vegetations with a possible impact lesion. He eventually underwent mitral valve replacement and thankfully on discharge months later had minimal residual neurological deficit.


2. A male in his 40s presented septic, drowsy, with vague complaints of pain in his R flank and down his R thigh. Examination did not reveal any septic focus relevant to the location of the pain, his urine was clear, and he had no septic focus in his abdominal, vertebrae or soft tissues. He did however have an obvious diastolic murmur, and it was unknown whether this was acute or chronic.

Bedside echo showed severe aortic regurgitation (AR). The LV was not yet significantly dilated, suggesting that the AR was acute. My imaging was sub-optimal, and I did not identify an obvious aortic valve (AV) vegetation - his scan was ‘indeterminate’.


I admitted the patient with heightened suspicion for IE as the primary septic focus. His comprehensive echocardiogram the following day confirmed an AV non-coronary cusp vegetation with acute severe AR.


3.  Another male in his 40s presented with a week of fever and heart failure symptoms - orthopnoea and dyspnoea on exertion. He had no known IE risk factors. He was overweight, however otherwise looked reasonably well from the end of the bed. On examination he had bilateral lung crackles, mild peripheral oedema, and a new murmur.




REFERENCES

  1. Naderi HR, Sheybani F, Erfani SS. Errors in diagnosis of infective endocarditis. Epidemiology and Infection. 2018; 146(3):394-400.

  2. Dickerman SA, Abrutyn E, Barsic B, et al. The relationship between the initiation of antimicrobial therapy and the incidence of stroke in infective endocarditis: an analysis from the ICE Prospective Cohort Study (ICE-PCS). American Heart Journal. 2007; 154(6):1086-94.

  3. Young WJ, Jeffery DA, Hua A, et al. Echocardiography in Patients With Infective Endocarditis and the Impact of Diagnostic Delays on Clinical Outcomes. The American Journal of Cardiology. 2018; 122(4):650-655.

  4. Al-Mogheer B, Ammar W, Bakoum S et al. Predictors of inhospital mortality in patients with infective endocarditis. The Egyptian Heart Journal. 2013; 65(3):159-162.

  5. Cahill TJ, Baddour LM, Habib G, et al. Challenges in Infective Endocarditis. Journal of the American College of Cardiology. 2017; 69(3):325-344.

  6. Thuny F, Di Salvo G, Disalvo G, et al. Risk of embolism and death in infective endocarditis: prognostic value of echocardiography: a prospective multicenter study. Circulation. 2005; 112(1):69-75.

  7. Sanfilippo AJ, Picard MH, Newell JB, et al. Echocardiographic assessment of patients with infectious endocarditis: prediction of risk for complications. Journal of the American College of Cardiology. 1991; 18(5):1191-9.

  8. Nunes MC, Gelape CL, Ferrari TC. Profile of infective endocarditis at a tertiary care center in Brazil during a seven-year period: prognostic factors and in-hospital outcome. International Journal of Infectious Diseases. 2010; 14(5):e394-8.

  9. Luaces M, Vilacosta I, Fernández C, et al. Vegetation size at diagnosis in infective endocarditis: influencing factors and prognostic implications. International Journal of Cardiology. 2009; 137(1):76-8.

  10. Long B, Koyfman A. Infectious endocarditis: An update for emergency clinicians. The American Journal of Emergency Medicine. 2018; 36(9):1686-1692.

  11. Bai AD, Steinberg M, Showler A, et al. Diagnostic Accuracy of Transthoracic Echocardiography for Infective Endocarditis Findings Using Transesophageal Echocardiography as the Reference Standard: A Meta-Analysis. Journal of the American Society of Echocardiography. 2017; 30(7):639-646.e8.

  12. https://www.asum.com.au/files/public/Education/CCPU/Syllabi/CCPU-Rapid-Cardiac-Echocardiography-Syllabus.pdf

  13. http://www.asum.com.au/files/public/Education/DDU/Syllabus/DDU-%28Critical-Care%29-Syllabus.pdf

  14. Saric M, Armour AC, Arnaout MS, et al. Guidelines for the Use of Echocardiography in the Evaluation of a Cardiac Source of Embolism. Journal of the American Society of Echocardiography. 2016; 29(1):1-42.

  15. Levitov A, Frankel HL, Blaivas M, et al. Guidelines for the Appropriate Use of Bedside General and Cardiac Ultrasonography in the Evaluation of Critically Ill Patients-Part II: Cardiac Ultrasonography. Critical Care Medicine. 2016; 44(6):1206-27.

  16. Bugg CW, Berona K. Point-of-Care Ultrasound Diagnosis of Left-Sided Endocarditis. The Western Journal of Emergency Medicine. 2016; 17(3):383.

  17. Cheng AB, Levine DA, Tsung JW, Phoon CK. Emergency physician diagnosis of pediatric infective endocarditis by point-of-care echocardiography. The American Journal of Emergency Medicine. 2012; 30(2):386.e1-3.

  18. Seif D, Meeks A, Mailhot T, Perera P. Emergency department diagnosis of infective endocarditis using bedside emergency ultrasound. Critical Ultrasound Journal. 2013; 5(1):1.

  19. Tsagaratos C, Taha FW. Recognizing infective endocarditis in the emergency department. The Western Journal of Emergency Medicine. 2012; 13(1):92-3.

  20. Walsh B, Bomann JS, Moore C. Diagnosing Infective Endocarditis by Emergency Department Echocardiogram. Academic Emergency Medicine. 2009; 16(6):572-573.

  21. Arthur J, Havyarimana J, Norse AB. Emergency Department Diagnosis of Septic Pulmonary Embolism due to Infectious Endocarditis Using Bedside Ultrasound. The Journal of Emergency Medicine. 2018; 55(3):378-382.

  22. Ramesh N, Lau M, Filopei J, Patrawalla P. Septic Endocarditis and Internal Jugular Vein Thrombosis: POCUS to the Rescue. Chest. 2016; 150(4):653.

  23. Pathak NJ, Ng L, Saul T, Lewiss RE. Focused cardiac ultrasound diagnosis of right-sided endocarditis. The American Journal of Emergency Medicine. 2013; 31(6):998.e3-4.

  24. https://emcrit.org/janus-general/

  25. Baddour LM, Wilson WR, Bayer AS, et al. Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association. Circulation. 2015; 132(15):1435-86.