Can infective endocarditis cause aortic regurgitation?

From the Guidelines

Infective endocarditis can indeed cause aortic regurgitation, as the infection can damage the aortic valve, leading to improper closure and subsequent regurgitation of blood from the aorta into the left ventricle. This condition involves bacterial or fungal infection of the heart's inner lining (endocardium), particularly affecting the heart valves. The infection can destroy valve tissue, create perforations, or cause vegetations (clumps of bacteria, platelets, and fibrin) that interfere with valve closure. The aortic valve is commonly affected in endocarditis, and the resulting damage can range from mild to severe regurgitation. Symptoms may include a new heart murmur, shortness of breath, fatigue, and signs of heart failure.

Key Points to Consider

• Infective endocarditis is a serious condition that can lead to significant morbidity and mortality if not properly managed.
• The infection can cause damage to the heart valves, including the aortic valve, leading to regurgitation.
• Treatment typically involves 4-6 weeks of intravenous antibiotics targeted to the specific causative organism, with common regimens including combinations of penicillins, aminoglycosides, or vancomycin depending on the pathogen.
• In severe cases where valve damage causes significant regurgitation and heart failure, surgical valve repair or replacement may be necessary even after the infection is controlled, as indicated by the 2015 ESC guidelines for the management of infective endocarditis 1.
• The decision to perform surgery should be based on the presence of heart failure, uncontrolled infection, or prevention of embolism, as outlined in the guidelines.

Management and Treatment

The management of infective endocarditis involves a multidisciplinary approach, including antibiotic therapy and potential surgical intervention. The choice of antibiotic regimen should be guided by blood culture results and susceptibility testing. In cases where surgical intervention is necessary, the timing and type of surgery should be determined by a team of cardiologists, cardiothoracic surgeons, and infectious disease specialists. The 2008 ACC/AHA guideline update on valvular heart disease provides additional guidance on the management of patients with valvular heart disease, including those with infective endocarditis 1.

Surgical Intervention

Surgical intervention may be necessary in cases where valve damage causes significant regurgitation and heart failure. The 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease provides guidance on the indications for surgery in patients with infective endocarditis, including those with valve stenosis or regurgitation resulting in heart failure, and those with infective endocarditis caused by fungal or other highly resistant organisms 1.

From the Research

Infective Endocarditis and Aortic Regurgitation

• Infective endocarditis (IE) can cause aortic regurgitation, as evidenced by several studies 2, 3.
• A study published in 2017 found that acute aortic regurgitation due to IE is a serious disease that usually requires surgical treatment 2.
• Another study published in 2021 identified clinical and echocardiographic predictors of decompensation in acute severe aortic regurgitation due to IE, including higher heart rate and diastolic mitral regurgitation 3.

Characteristics of Infective Endocarditis

• IE can involve almost any organ system in the body and is increasingly associated with health care contact, particularly in patients with intravascular prosthetic material 4.
• The diagnosis of IE may be difficult to establish and requires a combination of clinical, microbiological, and echocardiography results, as codified in the modified Duke criteria 4.
• IE is best managed by a multidisciplinary team with expertise in infectious diseases, cardiology, and cardiac surgery 4.

Clinical Manifestations and Management

• The clinical manifestations of IE can include valvular vegetation, abscess, periannular extension of infection, and myopericarditis 5.
• Echocardiography is crucial in the diagnosis of IE, but alternative imaging modalities are playing an increasing role in the diagnosis and management of IE 5.
• Multidisciplinary care is imperative to the management of IE, often requiring the expertise of cardiologists, cardiothoracic surgeons, infectious diseases specialists, radiologists, and neurologists 5.