From the Guidelines
Vegetation size on echocardiography is the most predictive echocardiographic parameter for endocarditis complications, with vegetations larger than 10 mm in diameter associated with increased risk of embolic events. The predictive value of vegetation size relates to the physical instability of larger vegetations, which are more prone to fragmentation and embolization to distant organs, particularly the brain, lungs, and spleen 1. Additionally, larger vegetations often indicate a more virulent infection with greater valvular destruction, which can lead to acute valvular regurgitation and subsequent heart failure. Other important but less predictive echocardiographic parameters include vegetation mobility, valvular destruction, perivalvular abscess formation, and prosthetic valve dehiscence.
When large vegetations are identified, particularly on the mitral valve, clinicians should consider early surgical intervention rather than prolonged antibiotic therapy alone, especially if the patient has already experienced an embolic event 1. The size and other characteristics of vegetations on echocardiography have been shown to be useful in predicting complications such as peripheral embolization 1. In left-sided native valve S. aureus endocarditis, the presence of an intracardiac abscess and left ventricular ejection fraction < 40% on echocardiography has been shown to be independent predictors of in-hospital mortality 1.
Key points to consider in the management of endocarditis include:
- Vegetation size and mobility on echocardiography
- Presence of perivalvular abscess or valvular perforation
- Left ventricular ejection fraction
- Presence of prosthetic valve dysfunction
- History of embolic events
- Type of infecting organism, with S. aureus being particularly virulent 1.
Overall, the management of endocarditis requires a multidisciplinary approach, with echocardiography playing a critical role in diagnosis, prognostication, and guiding treatment decisions 1.
From the Research
Echocardiographic Parameters for Endocarditis Complications
The most predictive echocardiographic parameter for endocarditis complications is:
- Vegetation size, with a size of >10 mm being a significant predictor of embolic events 2, 3, 4
- Vegetation mobility, with mobile vegetations being associated with a higher risk of embolism 3, 4
- Presence of periannular complications, prosthetic dysfunction, low left ventricular ejection fraction, pulmonary hypertension, and very large vegetations, which are all echocardiographic predictors of poor outcome 5
Predictive Value of Echocardiography
Echocardiography plays a key role in the diagnosis and prognosis assessment of patients with infective endocarditis, and is useful for:
- Assessing the severity of the disease 6
- Predicting short- and long-term prognosis 6
- Predicting embolic events 3, 4
- Follow-up of patients under specific antibiotic therapy 6
- Diagnosis and management of complications of IE 6
Embolic Events
Embolic events are more common in patients with: