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Infective endocarditis: innovations in the management of an old disease


The annual incidence of infective endocarditis (IE) is estimated to be between 15 and 80 cases per million persons in population-based studies. The incidence of IE is markedly increased in patients with valve prostheses (>4 per 1,000) or with prior IE (>10 per 1,000). The interaction between platelets, microorganisms and diseased valvular endothelium is the cause of vegetations and valvular or perivalvular tissue destruction. Owing to its complexity, the diagnosis of IE is facilitated by the use of the standardized Duke–Li classification, which combines two major criteria (microbiology and imaging) with five minor criteria. However, the sensitivity of the Duke–Li classification is suboptimal, particularly in prosthetic IE, and can be improved by the use of PET or radiolabelled leukocyte scintigraphy. Prolonged antibiotic therapy is mandatory. Indications for surgery during acute IE depend on the presence of haemodynamic, septic and embolic complications. The most urgent indications for surgery are related to heart failure. In the past decade, the prevention of IE has been reoriented, with indications for antibiotic prophylaxis now limited to patients at high risk of IE undergoing dental procedures. Guidelines now emphasize the importance of nonspecific oral and cutaneous hygiene in individual patients and during health-care procedures.

Key points

  • Infective endocarditis (IE) is a rare disease, but its incidence is highly variable according to the underlying heart disease; incidence is highest in patients with prior endocarditis.

  • The diagnosis of IE combines different factors that are not specific for IE when considered individually; the Duke–Li classification is the reference diagnostic criteria for IE but has suboptimal sensitivity.

  • Echocardiography remains the first-line imaging modality for the diagnosis of IE; growing evidence supports the usefulness of nuclear imaging in doubtful cases occurring on foreign material.

  • The main complications of IE are heart failure, persistent sepsis (in particular owing to perivalvular extension of infection) and embolic events, most often cerebral in location.

  • Treatment of IE is based on prolonged antibiotic therapy; valvular surgery is performed in approximately half of patients with IE during the initial course of antibiotic therapy.

  • Indications for antibiotic prophylaxis have been downgraded in guidelines, which now emphasize the importance of nonspecific hygiene measures.

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Review criteria

The PubMed database was searched to select articles for inclusion in this Review using the search terms “infective endocarditis” alone and combined with “epidemiology”, “pathophysiology”, “imaging”, “valvular surgery”, “transcatheter valves”, “prophylaxis” and “guidelines”. Only full-text papers in the English language were considered, and original papers were favoured over reviews. The authors selected papers published between 1990 and 2018. Reference lists of identified papers were searched for further leads, favouring papers published after 2010.

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Both authors contributed to researching data for the article, discussion of content, writing and reviewing and/or editing the manuscript before submission.

Correspondence to Bernard Iung.

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B.I. has received consultant fees from Edwards Lifesciences and speaker’s fees from Boehringer Ingelheim and Novartis. X.D. has received a grant from Pfizer.

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Supplementary information

Supplementary Video 1 Infective endocarditis on a rheumatic mitral valve with moderate stenosis. Large (18 mm) and very mobile vegetation inserted on the atrial side of the mitral valve with intermittent prolapse in the left ventricle during the diastole. Transthoracic echocardiography, parasternal long-axis view.

Supplementary Video 2 Infective endocarditis on a bicuspid aortic valve. Vegetations on both leaflets, partial prolapse of the anterior leaflet and lack of coaptation due to valve mutilation (left panel). The consequence is a severe aortic regurgitation with a large jet according to colour Doppler (right panel). Transoesophageal echocardiography.

Supplementary Video 3 Infective endocarditis on an aortic bioprosthesis. Periprosthetic posterior abscess fistulised in the aorta and the left ventricle causing severe aortic regurgitation according to colour Doppler. Transthoracic echocardiography, parasternal long-axis (left panel) and short-axis (right panel) views.

Supplementary Video 4 Infective endocarditis on an aortic bioprosthesis. Periprosthetic posterior abscess fistulised in the aorta and the left ventricle causing severe aortic regurgitation according to colour Doppler. Transthoracic echocardiography, apical 2 chamber view.

Supplementary Video 5 Infective endocarditis on an aortic bioprosthesis. Periprosthetic posterior abscess at the upper part of the prosthesis, fistulised in the aorta and the left ventricle. Transoesophageal echocardiography, long-axis view.

Supplementary Video 6 Infective endocarditis on an aortic bioprosthesis. Periprosthetic posterior abscess at the upper part of the prosthesis, fistulised in the aorta and the left ventricle causing severe aortic regurgitation according to colour Doppler. Transoesophageal echocardiography, long-axis (left panel) and short-axis (right panel) views.

Supplementary Video 7 Infective endocarditis on an aortic bioprosthesis. Perivalvular abscess at the upper part of the aortic prosthesis with systolic expansion. 3D transoesophageal echocardiography, short-axis views.

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Fig. 1: Pathophysiology of IE.
Fig. 2: PET–CT imaging of IE.
Fig. 3: Algorithm for the diagnosis of IE.