The prototypic lesion of infective endocarditis, the vegetation (Fig. 123-1), is a mass of platelets, fibrin, microorganisms, and scant inflammatory cells. Infection most commonly involves heart valves but may also occur on the low-pressure side of a ventricular septal defect, on mural endocardium damaged by aberrant jets of blood or foreign bodies, or on intracardiac devices themselves. The analogous process involving arteriovenous shunts, arterio-arterial shunts (patent ductus arteriosus), or a coarctation of the aorta is called infective endarteritis.
Vegetations (arrows) due to viridans streptococcal endocarditis involving the mitral valve.
Endocarditis can be classified according to the temporal evolution of disease, the site of infection, the cause of infection, or the predisposing risk factor (e.g., injection drug use, association with health care). Acute endocarditis is a hectically febrile illness that rapidly damages cardiac structures, seeds extracardiac sites, and, if untreated, progresses to death within weeks. Subacute endocarditis follows an indolent course; causes structural cardiac damage only slowly, if at all; rarely metastasizes; and is gradually progressive unless complicated by a major embolic event or a ruptured mycotic aneurysm.
In developed countries, the incidence of endocarditis ranges from 4 to 7 cases per 100,000 population per year and has remained relatively stable during recent decades. While congenital heart diseases remain a constant predisposition, predisposing conditions in developed countries have shifted from chronic rheumatic heart disease (still a common predisposition in developing countries) to illicit IV drug use, degenerative valve disease, and intracardiac devices. The incidence of endocarditis is notably increased among the elderly. In developed countries, 25–35% of cases of native-valve endocarditis (NVE) are associated with health care, and 16–30% of all cases are prosthetic-valve infections (PVE). The risk of PVE is greatest during the first 6–12 months after valve replacement; gradually declines to a low, stable rate thereafter; and is similar for mechanical and bioprosthetic devices. The incidence of infection involving transcatheter implanted aortic valves (a new form of PVE that is beyond the scope of this chapter) is 0.97% in the initial year of follow-up. Endocarditis involving cardiovascular implantable electronic devices (CIEDs)—primarily permanent pacemakers and implantable cardioverter-defibrillators—occurs in 0.5–1.14 cases per 1000 device recipients, with higher rates among patients with an implantable cardioverter-defibrillator than among those with a permanent pacemaker.
Although many species of bacteria and fungi cause sporadic episodes of endocarditis, a few bacterial species cause the majority of cases (Table 123-1). The oral cavity, skin, and upper respiratory tract are the respective primary portals for viridans streptococci, staphylococci, and HACEK organisms (Haemophilus species, Aggregatibacter species, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae). Streptococcus gallolyticus subspecies gallolyticus (formerly S. bovis biotype 1) originates from the gastrointestinal tract, where it is associated with polyps and colonic tumors, and enterococci enter the bloodstream primarily from ...