Complications

The complications of IE result from the local destructive effects of vegetations, their propensity to embolize, and epiphenomena (Table 4). The presence

Table 3

Cardiac Vegetations in Infective Endocarditis vs Nonvegetation Masses

Characteristics

Cardiac vegetations

Nonvegetative masses

Location Motion

Morphology

Echocardiography texture Accompanying features

Usually on valve suface facing path of blood flow (upstream)

Relatively independent of cardiac or valvular components; often oscillate or prolapse

Irregular morphology, sometimes lobulated or filiform

Same reflectivity as myocardium

Cardiac and extracardiac manifestations of infective endocarditis (Table 5)

Usually downstream surface of valve

Often concordant with other cardiac or valvular components

Morphology characteristic of underlying pathology

Often shows increased calcification or reflectivity

Usually absent

Table 4

Infective Endocarditis: Complications

Leaflet perforation

Valvular incompetence leading to heart failure

Perivalvular abscess

Atrioventricular valves: chordal rupture, leaflet perforation

Extension leading to aneurysm/pseudoaneurysm, fistula, or invasion of cardiac conducting system (Fig. 14A,B)

Coronary artery emboli leading to acute myocardial infarction

Pericarditis

• Extracardiac

Emboli: stroke, mycotic aneurysms, infarctions of renal, splenic, and pulmonary bed, osteomyelitis, septic arthritis, metastatic abscesses, gangrene

Immunological: glomerulonephritis, Roth spots, Janeway lesions and characteristics of vegetations seem to affect the prognosis and clinical course of patients. The frequency of complications seems to increase with greater mobility, extent, number, consistency, and increasing size of vegetations on repeat examinations. Always look for associated cardiac structural abnormalities in individuals with suspected or confirmed IE (Table 2). When present, these should be followed-up by serial examinations as these can guide decision making, including the need and timing of surgery. Echocardiography regression or disappearance of vegetations is not a sign of cure in IE.

Echocardiographic Features Suggesting the Need for Surgical Intervention

Whenever, possible surgical intervention for IE should be avoided owing to the high associated morbidity and risk of prosthetic valve infection. The decision to proceed to surgery is not clear cut, and should be tailored to each clinical state, aided by certain echocardiographic features.

Echocardiographic features portending adverse outcomes with need for surgical intervention include:

1. Prosthetic valve endocarditis.

2. Worsening native valvular regurgitation despite treatment (Fig. 19).

3. Sinus of Valsalva aneurysm.

a. With embolic phenomena.

b. Causing valvular obstruction.

c. Fungal endocarditis.

5. Aortic root and septal abscesses.

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