Endocarditis ecg signs. What is this disease? Complications of infective endocarditis

Endocarditis is inflammatory process occurring in the inner lining of the heart (endocardium). The main reason for its development is infection, but other pathologies should not be ruled out. The disease can equally affect both male and female populations. Very often, the disease overtakes the body of people taking various narcotic drugs. Propensity to develop pathological process It is also present in young patients, so it is important to know the causes and symptoms of the pathology in order to prevent the development of severe complications.

Reasons for development

The most likely cause of infective endocarditis is various factors. Their recognition guarantees a positive effect of treatment. The most basic causes of the inflammatory process in the endocardium are:

• diffuse connective tissue disease;
• trauma;
• poisoning with chemical elements;
• infections.

Manifestations of endocarditis

Symptoms of endocarditis appear the same in all patients on various stages ailment. According to them, it is not possible to recognize the cause of the disease, but they occur against the background of a lack of oxygen in the tissues. To make a diagnosis, some patient complaints are not enough, since the symptoms are very similar to others. pathological conditions. But they are very important for the victims themselves. Symptoms infective endocarditis indicate a malfunction in our "motor", so you need to urgently contact a therapist.

Infective endocarditis has the following manifestations:

• promotion temperature indicators body;
• shiver;
• increased sweating;
• skin diseases;
• eye manifestations;
• pain syndrome in the muscles and head.

Fever

This symptom is found in almost all people affected by infective endocarditis. Initially, the temperature indicators are moderate - 37–37.5 degrees. A few days later, they reach a dangerous mark of 39-40 degrees. This condition is due to the characteristics of the causative agent of pathology.

Very often, fever is the result of the influence of specific components. In the inflammatory process in the inner shell of the human “motor”, the waste products of the pathogen act as these substances. After entering the plasma, they affect the center responsible for thermoregulation and cause a rise in temperature.

When fever is absent or present slight increase temperature, then this is typical for the following category of people:

• elderly people;
• after ;
• with pronounced;
• With elevated content uric acid in plasma.

Complicating the diagnosis is the fact that a slight rise temperature regime not accompanied by heart symptoms. The fever lasts for 3-4 weeks.

This condition suggests an involuntary contraction muscle tissue manifested as trembling or convulsive state. Chills are a characteristic manifestation of sepsis, as a result of which the movement of bacteria in the plasma is observed and their damage to internal organs. Infective endocarditis is manifested in the form of chills at the time of an increase in body temperature.

excessive sweating

The root cause that a person begins to sweat a lot is a fever. The release of sweat contributes to the decline in the temperature of the victim. With sepsis, which causes infective endocarditis, such a symptom worries the victim, usually at night.

Skin diseases

Since harmful agents of an infectious nature affect the heart with a rush of blood, most people suffering from endocarditis can detect damage vascular walls. Manifestations similar condition are formed on the skin small rash, redness.

Visual disorders

Mechanism of Education eye symptoms has similarities with skin. They include a number of signs that form pinpoint bleeding in the eye area. The patient can detect such a sign in himself. The pathological process is manifested by red pigmentation on the conjunctiva of a small size. They can be detected on their own by pushing the lower eyelid down.

While being examined by an ophthalmologist, Roth spots may be seen. They are areas of hemorrhage that affect the tissue of the eye. It is possible to identify them only during the diagnosis of the fundus.

Pain in the head and muscles

Symptoms of this kind visit people who have infective endocarditis. If a person is struck by another form of the disease, then headaches and muscle pain he does not have. The reasons for such formations are intoxication of the body caused by the multiplication of microbes. Often they coincide with the first stage of temperature increase.

Rheumatoid form of the disease

This condition is characterized by symptoms of damage to the heart valves. In the early stages of development, rheumatoid endocarditis does not cause any serious manifestations. Install accurate diagnosis is possible only during a thorough cardiological examination and according to the results laboratory research. Formation of the disease late stage leads to the formation of symptoms of insufficient work of the heart. Rheumatic endocarditis and its symptoms begin to affect other organs and systems.

The disease is often limited only to manifestations of the heart. Therefore, patients do not feel any serious manifestations characteristic of endocarditis.

Septic form of the disease

Septic endocarditis is a specific form, characteristic features which is valvular heart disease. Bacterial endocarditis is classified according to the nature of the course or the presence of an accompanying disease.

Given the nature of the development of the inflammatory process, acute, subacute and prolonged septic endocarditis are isolated. The acute form lasts about 14 days, subacute - 3 months, protracted - worries people for months and even years. Today, doctors note that the acute forms are gone, so they diagnose subacute and protracted. Bacterial endocarditis, taking into account the background pathology, can be: primary and secondary.

Septic endocarditis manifests itself in the following form:

• hemorrhage (bleeding of blood from the vessels) into the conjunctiva of the eye;
• thickenings in the form of nodules form on the palms;
• wasting of the fingers;
• hemorrhage in the skin.

Illness in young patients

Infective endocarditis in children is an inflammatory lesion of the endocarditis of the heart. Such a pathological process has an infectious breed.

Often the disease serves as a complication of congenital heart disease or chronic form especially after surgery. Contribute to the formation of defects various kinds viruses, fungi. Often the cause of the disease lies in defects immune system, hearth chronic infection. In infective endocarditis in young patients, mortality is very high.

There are congenital and acquired forms of the disease. The main symptoms of pediatric infective endocarditis include:

• rapid weight loss;
• weakness;
• increased sweating;
• fever in the evening;
• pain in joints and muscles.

The disease can begin acutely and be accompanied by the rapid formation of symptoms. However, most often the first stage of the pathology proceeds slowly and imperceptibly. The duration of the process is sometimes delayed and difficult to treat.

Over time, infective endocarditis becomes generalized. As a result, damage is done to other organs. Infective endocarditis in young patients can cause complications such as blood clots, resulting in blockage of blood vessels in the internal organs and brain. Against the background of insufficient work of the heart, there is difficulty breathing, pallor and cyanosis skin, puffiness. The symptoms of the disease are so diverse that it is very difficult to immediately establish the disease.

Diagnostic studies

To make a diagnosis, the patient must undergo a certain examination. Only after that, the doctor will be able to accurately establish infective endocarditis and prescribe effective therapy. Diagnostics includes:

• listening to the heart, during which coarse noises can be detected;
• electrocardiography;
• x-ray;
• plasma bacterial cultures.

When the results of a complete examination are in the hands of the patient, you can go directly to your doctor. Try to pass all the tests as soon as possible, as the time spent may then affect your health and the effectiveness of subsequent treatment.

Therapeutic activities

Treatment of infective endocarditis includes a set of measures to eliminate the inflammatory process in the inner shell of the human "motor". Most often, antibiotic therapy and surgical intervention are involved in the process. If formation takes place, then treatment should be aimed at correcting it. If infective endocarditis is suspected, the patient should be urgently hospitalized.

Medical therapy

When treating endocarditis with antibiotics, you should discuss this issue with your doctor. Their appointment takes into account the degree of sensitivity. The course of admission should be at least 4-6 weeks. As a rule, the specialist prescribes a complex to the patient medical preparations in order to achieve maximum effect. It can be:

• Ampicillin-Sulbactam with Gentamicin;
• Vancomycin and Ciprofloxacin.

In addition to antibiotic drugs, the treatment of infective endocarditis involves drugs that affect the immune system.

If there is a disease of a non-bacterial nature, then for the treatment of endocarditis, the specifics of the underlying disease must be taken into account. When diagnosed endocrine pathology, the patient is obliged to take tests for hormones and be treated under the supervision of an endocrinologist. Endocarditis resulting from intoxication can be cured by stopping the use of a certain type of toxin.

Operation

The elimination of the inflammatory process by surgery involves the removal of the affected area of ​​the heart valve with further prosthetics. If possible, the patient undergoes plastic surgery to save their own valves. After rehabilitation period The patient must be under medical supervision. For six months, you need to go for examinations every month in order to detect a possible return of infection and control general well-being. Further examinations should take place 2 times a year.

Effects

Complications from the presented disease arise due to growths on the heart valves. They can detach and affect other organs and systems with the flow of blood. If they get stuck in a small vessel, this will cause an acute lack of blood supply, resulting in tissue death. You can also damage the kidneys. Such a complication manifests itself in the form of an abscess and infarction of the organ. Nervous system gives complications in the form of a stroke, meningitis. The most dangerous complication is the formation of blood clots in pulmonary artery. This condition leads to death.

Prevention

If you do not want your body to pick up such a pathology, then you should know the basic measures that can protect you from endocarditis. Prevention involves the following series of actions:

1. When using narcotic drugs, it is urgent to refuse them, since such people are at greater risk of getting sick.
2. Those who have artificial valves or chronic heart disease should always be under the supervision of a specialist.
3. Constantly monitor the quality of processing of medical equipment and ask the doctor about the quality of sterilization.

Every person, both an adult and a child, can get sick with endocarditis. The reason for this pathology lies in the defeat of the body by an infectious agent. The disease manifests itself with chills, fever and headaches. This condition can be cured, but only if integrated approach. If you delay with therapy, you can get a number of unpleasant and dangerous complications, which will be very difficult to treat later.

Endocarditis is a pathological process that affects the inner lining of the heart, as well as the aortic and heart valves.

This disease is extremely dangerous not only for health, but also for human life. If the treatment is not started on time, the consequences can be the saddest, up to the development of heart failure, blockage of the blood vessels of the internal organs and the occurrence of immune diseases.

Endocarditis can be infectious (bacterial) and non-infectious nature. And although it is the first type of endocarditis that often occurs, there are cases of its development against the background of immunopathological processes and mechanical damage to the walls of the heart.

What is it in simple words?

The endocardium is the inner lining of the heart, and when it becomes inflamed, a disease called endocarditis develops. The acute form of the disease is often not independent disease- this is just one of the manifestations of other pathological processes occurring in the patient's body.

About endocarditis, as an independent disease, they speak only if it subacute course. In this situation, it is often caused by a streptococcal infection.

Epidemiology

The disease occurs in people in all countries of the world without exception, and most often it develops in males. The incidence is 3.1 - 11.6% per 100,000 inhabitants.

In recent years, endocarditis has increasingly affected the elderly. So, if in developed countries people aged 35-40 suffered from this pathology, today the patients suffering from it are people over 50. At the same time, there is a risk of developing endocarditis is much higher in young children. This is especially true for children who have been diagnosed with congenital heart defects.

The mortality rate from this disease ranges from 15-45%.

Reasons for the development of the disease

The type of endocarditis depends on whether it was caused by a bacterial infection or developed under the influence of other diseases.

So, infective endocarditis can be:

• viral;
• fungal;
• bacterial.

The most common is bacterial endocarditis, which develops under the influence of pathogens that can enter the inner lining of the heart through the blood from:

• purulent rash on the body;
• inflamed or clogged with purulent plugs of the tonsils;
• teeth affected by caries;
• bodies respiratory system(with the infectious nature of the existing disease).

Pathologies of the urogenital area, as well as infection during the process of prosthetic heart valves, can also cause the development of bacterial endocarditis.

Non-infectious endocarditis

The development of non-infectious endocarditis often occurs under the influence of autoimmune diseases. In this case, the human body begins to produce autoimmune antibodies that attack not foreign, but healthy, pathologically unchanged cells. As a result, aseptic endocarditis develops, which, in turn, can lead to valvular heart disease.

One of the common causes of non-infectious endocarditis is. This is a disease that has allergic nature, and often develops against the background of a sore throat caused by streptococcus viridans. AT advanced stage tonsillitis also affects the heart tissues, and the endocardium suffers from the pathological process first of all.

The development of endocarditis is not the last effect of the transferred angina of streptococcal etiology. These microorganisms produce a specific M-protein, due to the entry of which into the blood, an acute autoimmune reaction of the body to the connective tissue occurs. And although streptococci do not take an active part in the development of inflammatory processes in the endocardium, nevertheless, endocarditis after undergoing a course of therapy for tonsillitis is not such a rare phenomenon.

The development of endocarditis in young children requires special attention. Pathology can be both congenital and acquired.

So, congenital endocarditis is a consequence of diseases of an infectious origin transferred by a pregnant woman. The same factors as in adults can serve as the causes of the acquired form of pathology.

Pathogenesis

necessary for the development of endocarditis certain conditions, which are often associated with prolonged exposure of the infectious agent to the endocardium. Yes, in this case Tonsillitis, furunculosis, periodontitis, etc. can lead to a pathological process.

The causes of acquired endocarditis include penetration bacterial infection into the blood due to:

• surgical interventions in the area of ​​various internal organs;
• tooth extraction;
• insertion of a catheter into a vein or bladder etc.;
• conducting bronchoscopy;
• intravenous administration of drugs, etc.

The pathological process is often localized on those heart valves that were previously subject to changes due to congenital, rheumatic heart lesions, or after the patient underwent prosthetic heart valves. Most often, the following valves are affected:

• aortic;
• tricuspid;
• mitral;
• pulmonary.

At the same time, the tricuspid and pulmonary heart valves most often undergo changes in injection drug users.

The basis of the pathological process is considered to be destructive-ulcerative endocarditis, accompanied by thromboembolic overlays. They subsequently lead to the development of thromboembolism.

In addition, the autoimmune mechanisms of the body are directly involved in the development of endocarditis. A blood test reveals a large number of antibodies to certain representatives pathogenic microflora. Circulating immune complexes are also identified that can lead to the development of vasculitis or glomerulonephritis.

Classification

Endocarditis in its origin is:

• primary, when the pathological process develops in the area of ​​​​absolutely healthy valves;
• secondary, developing on previously altered heart valves (due to congenital defects, rheumatism, etc.).

According to the classification according to clinical course endocarditis happens:

1. Acute, the symptoms of which persist for 1-2 months. Common causes of this form of endocarditis are caused by streptococcal microflora, injuries, therapeutic or diagnostic interventions in the heart area.
2. Subacute. This phase can last 2 months or more. It develops against the background of untreated acute endocarditis.
3. Chronic, prone to relapse. Clinical picture this form of endocarditis can persist for six months. Chronicization of the pathological process can occur against the background of deep myocardial damage, or in violation of the functions of the valvular apparatus.

Chronic endocarditis is common in newborns and toddlers with congenital heart defects. This form of the pathological process is also widespread among drug addicts and patients who have undergone surgery.

Symptoms

Clinical manifestations of endocarditis are directly dependent on its type. They can rise and fall, replace each other or appear all together.

Acute endocarditis is characterized by:

• febrile or pyretic fever;
• severe chills, which are especially acute when the body temperature rises;
• hyperhidrosis;
• joint and muscle pain;
• physical weakness, lethargy;
• headaches;
• grayish or yellowish skin tone (sometimes with red spots on it);
• painful nodules localized on the fingers of the upper limbs;
• hemorrhages in the conjunctiva.

Subacute infective endocarditis is characterized by the following symptoms:

• febrile fever;
• sleep disorders;
• trembling in the body;
• causeless weight loss;
• skin acquisition of a coffee-milk shade;
• the appearance of a red rash all over the body;
• the appearance of subcutaneous small painful nodules.

The chronic form of endocarditis is characterized by the same clinical manifestations that can last for 6 months or more. During this period of time, there significant reduction body weight, and the patient's fingers acquire a shade of drumsticks. Nails become dull and brittle, begin to peel and break. Numerous hemorrhages appear under the nails, and painful plaques form on the skin of the hands and feet.

The development of heart disease, first of all, signals shortness of breath. At first, it manifests itself during physical exertion, but over time it also occurs in a state of absolute rest. The patient is concerned about pain behind the sternum, increases heartbeat. The patient's body temperature has no effect on these anomalies.

With the development of glomerulonephritis or kidney infarction, first of all, edema forms on the patient's face. Then there is a violation of the process of urination, the volume of excreted daily urine decreases. Urine becomes reddish, acquires bad smell, and this process is accompanied by an increase in body temperature and intense pain in the lower back.

Pulmonary embolism is characterized by severe shortness of breath and a feeling of acute lack of air. The patient complains of chest pain. Against the background of oxygen starvation, the complexion becomes purple or cyanotic, serious disturbances in consciousness occur.

Symptoms of infective endocarditis develop in 3 stages:

1. Infectious-toxic. At this time, pathogens enter the bloodstream and "settle" on the heart valves. Rapidly multiplying, they form specific outgrowths - vegetation.
2. Infectious-allergic, when the immune system is activated in response to an attack by pathogenic microflora. In this case, damage to internal organs occurs: kidneys, liver, myocardium, etc.
3. Dystrophic. This phase of endocarditis development is characterized by the occurrence of severe complications. There is necrosis of cardiac tissues and severe damage to many organs of internal secretion.

If endocarditis is rheumatic in nature, then it develops, as a rule, against the background of glomerulonephritis or tonsillitis, accompanied by the release of a specific beta-hemolytic streptococcus. After attenuation of the symptoms of the pathological process, the patient complains of a breakdown, weakness, general malaise and rapid fatigue.

Then fever develops again - subfebrile or even febrile. The patient complains of pressing, stabbing or aching sensations in the region of the heart. Against the background of such a picture, other symptoms of rheumatism may appear: in particular, a periodic increase in large joints, their soreness. These signs go away on their own, but tend to reappear.

Danger and complications

The most common complications of endocarditis include:

• development ;
• thromboembolism;
• vices or chronic inflammation heart valves.

Let's consider each of the situations in more detail.

1. In chronic heart failure, the pumping and contractile function of the heart is significantly reduced. This deviation is due to damage to the myocardium and heart valves.
2. Thromboembolism is one of the most dangerous complications of endocarditis. When a blood clot breaks off, it can enter the pulmonary circulation, which, in turn, can lead to blockage of the pulmonary artery. Penetration blood clot in a large circle of blood flow causes a violation of blood circulation in many internal organs and parts of the body: limbs, spleen, gastrointestinal tract, etc.
3. Prolonged chronic inflammation. Prolonged exposure to pathogenic microflora in endocarditis can lead to the formation of multiple abscesses in the body. This, in turn, can cause the development of sepsis.

Often with infective endocarditis, the development of renal and liver failure. No less severe complications of pathology can also include:

• embologenic and;
• inflammatory processes in the tissues of the lining of the brain;
• the formation of intracranial abscesses;
• phlebitis;
• thrombosis, etc.

In particular severe cases death is possible.

Diagnostics

In order to make sure that the diagnosis is correct, the doctor, first of all, collects an anamnesis. During the interview of the patient, he reveals his tendency to cardiovascular diseases, carefully studies the symptoms that disturb the patient and the frequency of its manifestations.

Auscultation and percussion of the region of the heart are of great importance in the diagnosis. Due to inflammation, there is a violation of the organ, which is fixed by the doctor when performing these manipulations.

Based on the data obtained, the cardiologist concludes that instrumental and laboratory diagnostic procedures are necessary:

1. An extended blood test. In endocarditis, there is an increase indicators of ESR and an increase in leukocyte levels.
2. Bacteriological examination of venous blood, which is carried out three times. It is necessary to determine the specific type of pathogens in case of suspected infectious nature of endocarditis.
3. EchoCG.

With the help of the last two procedures, the presence of vegetations in the region of the heart, as well as its structural changes, are revealed.

Treatment of infective and non-infectious endocarditis

With relatively easy course infective endocarditis, antibiotic therapy is practiced, in severe - surgical excision inflamed heart tissue. If there is a heart disease, all the efforts of doctors should be aimed at correcting the functioning of the organ.

Antibiotics for treatment infective endocarditis prescribed exclusively by a doctor! The course of therapy lasts from 4 to 6 weeks. Combination antimicrobials are often prescribed to achieve a more pronounced and faster treatment result. In addition to antibiotic therapy, general strengthening treatment is carried out. It is based on the use of immunoglobulins, anti-infective drugs and hormonal agents from the GCS group.

If a endocarditis is non-infectious p, then its treatment depends on the specifics of the underlying disease. In case of pathologies of the endocrine system, it is necessary to take a blood test from a vein to determine the level of hormones. If abnormalities are found, the patient will need to undergo therapy with an endocrinologist.

Endocarditis due to alcohol intoxication or poisoning harmful substances, is treated by avoiding or avoiding contact with the toxin.

Operation

The operation for endocarditis consists in excising the affected areas of the heart valve with their subsequent prosthetics. If there is a possibility of plastic surgery, then there is no need to replace natural valves with artificial ones.

After discharge from the hospital, the patient must undergo an additional course of outpatient monitoring. For six months, he will have to visit the clinic every month for regular examinations by a doctor who will evaluate the effectiveness of the therapy and the risk of recurrence of the pathology. After that, medical examinations will be carried out twice a year.

Forecast for life

The prognosis of life after endocarditis is conditionally unfavorable. Even with the use of broad-spectrum antibiotics, 30% of patients die from severe complications. However, timely antibiotic therapy increases the patient's chances of complete cure and restoration of performance.

Relapses of endocarditis occur 4 weeks after treatment. They can occur due to improperly selected antibiotics or the inappropriate use of them. A repeated outbreak of the disease leads to severe damage to the heart valves, and also increases the risk of developing CHF.

Prevention of endocarditis

To prevent the development of endocarditis, it is necessary:

• early detection and treatment infectious diseases Key words: caries, bacterial pathologies of the oropharynx and nasopharynx;
• regularly conduct prophylactic antibiotic therapy in individuals who are at risk;
• avoid stress;
• give preference to moderate physical activity;
• treat viral diseases in time;
• strengthen the immune system;
• carry out MMR immunization.

If a rupture of the spleen has become a complication of endocarditis, the patient is referred to. If necessary, prosthetics of the affected valves require intervention.

Infective endocarditis (IE)- this is an infectious, more often bacterial, polypous-ulcerative lesion of the valvular apparatus of the heart and parietal endocardium, accompanied by the formation of vegetations and the development of valve insufficiency due to the destruction of its valves, characterized by systemic damage to blood vessels and internal organs, as well as thromboembolic complications.

Epidemiology. The incidence of infective endocarditis averages 30-40 cases per 100,000 population. Men get sick 2-3 times more often than women, among the sick people of working age (20-50 years) predominate. Distinguish primary IE developing against the background of intact valves (in 30-40% of cases), and secondary IE, developing against the background of previously altered valves and subvalvular structures (congenital and acquired valvular heart disease, prosthetic valves, prolapse mitral valve, postinfarction aneurysms, artificial vascular shunts, etc.).

In recent years, there has been a steady increase in the incidence of IE, which is associated with the widespread use of invasive methods of examination and surgical treatment, an increase in drug addiction and the number of people with immunodeficiency states.

The features of "modern" infective endocarditis include:

The increase in the frequency of the disease in the elderly and senile age (more than 20% of cases).

An increase in the frequency of the primary (on intact valves) form of IE.

The emergence of new forms of the disease - IE of drug addicts, IE of a prosthetic valve, iatrogenic (nosocomial) IE due to hemodialysis, infection of intravenous catheters, hormone therapy and chemotherapy.

Mortality in infective endocarditis, despite the emergence of new generations of antibiotics, remains at a high level - 24-30%, and in the elderly - more than 40%.

Etiology IE is characterized by a wide range of pathogens:

1. The most common cause of the disease are streptococci(up to 60 - 80% of all cases), among which the most common pathogen is viridescent streptococcus(in 30 - 40%). Factors contributing to the activation of streptococcus are purulent diseases and surgical interventions in the oral cavity and nasopharynx. Streptococcal endocarditis is characterized by a subacute course.

In recent years, the etiological role has increased enterococcus, especially in IE in patients who have undergone abdominal surgery, urological or gynecological surgery. Enterococcal endocarditis is characterized by a malignant course and resistance to most antibiotics.

2. In second place in frequency among the etiological factors of IE is Staphylococcus aureus(10-27%), the invasion of which occurs against the background of surgical and cardiosurgical manipulations, with injection drug addiction, against the background of osteomyelitis, abscesses of various localization. Staphylococcal endocarditis is characterized by an acute course and frequent damage to intact valves.

3. The most severe are IE caused by gram-negative microflora(Escherichia, Pseudomonas aeruginosa, Proteus, microorganisms of the NASEK group), which develop more often in injection drug addicts and people suffering from alcoholism.

4. Against the background of immunodeficiency states of various origins, IE of mixed etiology develops, including pathogenic fungi, rickettsia, chlamydia, viruses and other infectious agents.

Thus, the most frequent gateway of infection are: surgical interventions and invasive procedures in the oral cavity, urogenital area, associated with the opening of abscesses of various localization, heart surgery, including valve replacement, coronary artery bypass grafting, prolonged stay of the catheter in a vein, frequent intravenous infusions, especially injection drug addiction, chronic hemodialysis.

Due to the frequent initiation of antibiotic therapy before the blood test of patients with IE for sterility, it is not always possible to identify the causative agent of the disease. In 20-40% of patients, the etiology of the disease remains unknown, which makes it difficult to prescribe adequate antibiotic therapy.

Pathogenesis. In the development of IE, the following pathogenetic mechanisms can be distinguished:

1. transient bacteremia, which can be observed during any surgical interventions on the organs of the abdominal cavity, genitourinary system, on the heart, blood vessels, organs of the nasopharynx, during tooth extraction. The source of bacteremia can be purulent infections of various localization, invasive studies of internal organs (bladder catheterization, bronchoscopy, colonoscopy, etc.), as well as non-compliance with sterility when injecting drug addicts. Thus, transient bacteremia is common and does not necessarily lead to IE. For the occurrence of the disease, additional conditions are necessary.

2. Endothelial damage develops as a result of exposure to the endocardium of high-speed and turbulent blood flows, due to metabolic disorders of the endocardium in elderly and senile people. In the presence of initial valvular pathology, the risk of bacteremia transformation into IE reaches 90% (according to M.A. Gurevich et al., 2001). Many invasive diagnostic and surgical interventions are accompanied by damage to the endothelium and, therefore, high risk development of IE.

3 . In the area of ​​damaged endothelium, most often on the surface of the cusps of the heart valves occurs platelet adhesion, their aggregation and the formation of platelet parietal thrombi with fibrin deposition. Under conditions of bacteremia, microorganisms from the bloodstream are deposited on microthrombi and form colonies. On top of them, new portions of platelets and fibrin are layered, which cover microorganisms from the action of phagocytes and other factors of the body's anti-infective defense. As a result, large polyp-like accumulations of platelets, microorganisms and fibrin are formed on the surface of the endothelium, which are called vegetations. Microorganisms in vegetations have favorable conditions for reproduction and vital activity, which leads to the progression of the infectious process.

4. Weakening of body resistance as a result of various external and internal factors is necessary condition for the development of an infectious focus in the heart under conditions of bacteremia.

5. As a result infectious destruction the tissues of the valve leaflets and subvalvular structures perforate the leaflets, tear off the tendon filaments, which leads to the acute development of insufficiency of the affected valve.

6. Against the background of a pronounced local infectious destructive process in the body, general immunopathological reactions naturally develop (inhibition of the T-system of lymphocytes and activation of the B-system, the formation of circulating immune complexes (CIC), the synthesis of autoantibodies to own damaged tissues, etc.), which leads to immune generalization process. As a result of immune complex reactions, systemic vasculitis, glomerulonephritis, myocarditis, polyarthritis, etc. develop.

7. IE is characterized thromboembolic complications: infected thromboemboli, which are particles of vegetations or a destroyed valve, migrate along the arterial bed of the large or small circle of blood circulation, depending on the damage to the endocardium of the left or right chambers of the heart, and form microabscesses of organs (brain, kidneys, spleen, lungs, etc.).

8. Progression of IE naturally leads to the development heart and kidney failure.

Pathoanatomy. The left parts of the heart are most often affected - the aortic and mitral valves, with IE in drug addicts - mainly the tricuspid valve. Vegetations are detected on the endocardium, consisting of platelets, fibrin and colonies of microorganisms, perforation or detachment of the valves, rupture of tendon chords. Vegetations often occur with valve insufficiency than with valvular stenosis, and are located mainly on the atrial side of the mitral valve or on the ventricular side - the aortic valve. Microaneurysms of vessels, abscesses of internal organs are characteristic.

Classification of IE

Clinical and morphological:

primary IE,

secondary IE.

By etiology: streptococcal, enterococcal, staphylococcal, proteic, fungal, etc.

With the flow:

acute, lasting less than 2 months,

subacute, lasting more than 2 months,

chronic relapsing course.

Special forms of IE:

Hospital (nosocomial)) IE:

prosthetic valve IE,

IE in persons with a pacemaker (pacer),

IE in people on program hemodialysis.

IE in drug addicts

IE in the elderly and senile

Clinical picture:

The current clinical course of IE is characterized by a predominance of

subacute or atypical forms of the disease with blurred clinical symptoms. Sometimes the disease is diagnosed only at the stage of acute destruction of the heart valves or the development of systemic immunopathological processes in the form of vasculitis, glomerulonephritis, etc.

When describing the clinic of IE, domestic scientists (A.A. Demin, 2005) traditionally distinguish 3 pathogenetic stages of the disease, which differ in clinical, laboratory and morphological parameters and principles of treatment:

Infectious-toxic.

Immunoinflammatory.

Dystrophic.

Complaints. The first symptoms usually appear 1 to 2 weeks after the episode of bacteremia. It - fever and intoxication. In subacute endocarditis, the disease begins with subfebrile temperature, which is accompanied by general weakness, chilling, sweating, fatigue, decreased appetite, and palpitations. During this period, the correct diagnosis, as a rule, is not established. The resulting symptoms are regarded as a viral infection, myocarditis, tuberculosis intoxication, etc.

A few weeks later, a hectic or persistent fever is established with a rise in body temperature to 38-39 ° C and severe chills, night sweats, weight loss of 10-15 kg, headaches, arthralgia and myalgia. Cardiac complaints appear and progress: shortness of breath with physical activity, pain in the region of the heart, persistent tachycardia. Despite the severity of clinical symptoms, the diagnosis of IE in the absence of signs of an established heart disease may not yet be established. At this time, the identification of vegetations on the valves using echocardiography may be decisive. With the development of a defect in the affected valve, signs of left or right ventricular failure quickly appear, which is accompanied by characteristic physical and instrumental findings, making the diagnosis of IE obvious. With the formation of heart disease against the background of perforation of the valve leaflets and destruction of valve vegetations, thromboembolic complications often occur with the development of ischemic stroke, infarction of the spleen, kidneys (with left-sided IE) and lungs (with right-sided IE), which is accompanied by characteristic complaints. Fungal IE is characterized by thromboembolism in the arteries of the extremities with the development of mycotic aneurysms or foot necrosis.

In a later immuno-inflammatory stage, complaints appear that indicate the development of glomerulonephritis, hemorrhagic vasculitis, myocarditis, arthritis, etc.

objectively comes to light pallor of the skin with a grayish-yellowish tinge (“coffee with milk” color), which is associated with anemia characteristic of IE, involvement of the liver and hemolysis of erythrocytes. Patients lose weight rapidly. Characteristic changes in the terminal phalanges of the fingers are revealed in the form "drum sticks" and nails by type "watch glasses" developing sometimes already after 2 - 3 months of the disease. On the skin of patients (on the front surface chest, on the limbs) can be observed petechial hemorrhagic eruptions(painless, not blanching when pressed). Sometimes petechiae are localized on the transitional fold of the conjunctiva of the lower eyelid. Lukin spots or on the oral mucosa. In the center of small hemorrhages in the conjunctiva and mucous membranes there is a characteristic zone of blanching. similar in appearance Roth spots are determined on the retina during the study of the fundus. On the soles and palms of the patient, painless red Janeway spots with a diameter of 1 - 4 mm. Perhaps the appearance of linear hemorrhages under the fingernails. Characteristic Osler's nodules- painful reddish formations the size of a pea, located in the skin and subcutaneous tissue on the palms and soles, associated with the development of thrombovasculitis. Positive pinching symptoms (Hechta) and Rumpel–Leede–Konchalovsky test, which indicate increased fragility of small vessels due to vasculitis. During the test, a blood pressure cuff is applied to the upper arm and a constant pressure of 100 mmHg is created in it for 5 minutes. With increased vascular permeability or thrombocytopathy (decrease in platelet function), more than 10 petechiae appear below the cuff in an area limited by a diameter of 5 cm.

When researching lymph nodes often revealed lymphadenopathy.

With the development of heart failure, external signs congestion in the systemic or pulmonary circulation

(orthopedic position, cyanosis, swelling of the legs, swelling of the neck veins, etc.).

With thromboembolic complications, characteristic external signs are also revealed: paralysis, paresis, signs of pulmonary embolism, etc.

Cardiac manifestations of IE:

In the acute course of IE and the rapid destruction of the affected valve, acute left ventricular or right ventricular failure develops with characteristic objective signs. Damage to the aortic valve is noted in 55 - 65% of cases, mitral valve - in 15 - 40%, simultaneous damage to the aortic and mitral valves - in 13%, tricuspid valve - in 1-5%, but among drug addicts this localization is detected in 50% of patients .

Percussion and auscultatory signs of valvular defects in primary IE, the nature of the pulse and blood pressure generally correspond to the physical manifestations of rheumatic heart disease.

It is difficult to diagnose IE associated with existing congenital or rheumatic heart disease. In differential diagnosis, along with the history and characteristic extracardiac signs of IE, the appearance of new or changes in previously existing heart murmurs due to the formation of new heart defects is taken into account.

Changes abdominal organs are manifested in an increase in the liver and splenomegaly (in 50% of patients) associated with generalized infection and frequent thromboembolic infarcts of the spleen.

Complications of IE:

Abscess of the annulus of the valve and its destruction.

diffuse myocarditis.

Heart failure, including acute with valve destruction.

Thromboembolism (in 35–65%) of patients.

Myocardial abscess, septic infarction of the lungs, spleen, brain.

Glomerulonephritis leading to chronic renal failure.

Diagnostics:

1. Complete blood count detects leukocytosis with a shift of the leukoformula to the left, an increase in ESR up to 50-70 mm / hour, normochromic anemia due to depression bone marrow. An increase in ESR usually persists for 3–6 months.

2. Biochemical blood test reveals a pronounced dysproteinemia due to a decrease in albumin and an increase in the content of α 2 and γ-globulins, the content of fibrinogen, seromucoid increases, C-reactive protein appears, positive sedimentary tests - formol, sublimate, thymol. In 50% of patients, rheumatoid factor is detected.

3. Blood culture for sterility may be decisive in confirming the diagnosis of IE and choosing an adequate antibiotic therapy. To obtain reliable results, blood sampling should be carried out before the start of antibiotic therapy or after a short-term withdrawal of antibiotics in compliance with all the rules of asepsis and antisepsis by puncture of a vein or artery. In the area of ​​the puncture of the vessel, the skin is treated twice with an antiseptic, the vein should be palpated with sterile gloves, 5–10 ml of venous blood is taken from the vein in 2 vials with nutrient media and immediately sent to the laboratory.

In acute IE, blood is taken three times with an interval of 30 minutes at the height of fever; in subacute IE, blood is taken three times within 24 hours. If after 2-3 days the growth of the flora is not obtained, it is recommended to sow 2-3 more times. With a positive result, the number of bacteria is from 1 to 200 in 1 ml of blood. Their sensitivity to antibiotics is determined.

4. Electrocardiography may reveal signs of focal or diffuse myocarditis, thromboembolism in the coronary arteries is accompanied by ECG signs of myocardial infarction, thromboembolism in the pulmonary artery (PE) will be manifested by ECG signs of acute overload of the right ventricle.

5. Echocardiography in many cases, it allows to identify direct signs of IE - vegetation on the valves, if their size exceeds 2-3 mm, to assess their shape, size and mobility. There are also signs of rupture of the tendon chords, perforation of the valve leaflets, and the formation of valvular heart defects.

Infective endocarditis (IE) is inflammatory disease infectious nature with damage to the valves of the heart and parietal endocardium, leading to the destruction of the valvular apparatus. The course of the disease is acute or subacute according to the type of sepsis with the circulation of the pathogen in the blood, thrombohemorrhagic and immune changes and complications.

Epidemiology of endocarditis

The incidence of IE is recorded in all countries of the world and ranges from 16 to 59 cases per 1,000,000 people, in Russia - 46.3 per 1,000,000 people per year and is steadily increasing. Men get sick 1.5-3 times more often than women. The most common endocardial lesion occurs at the age of about 50 years, ¼ of all cases are recorded in the age group of 60 years and older.

The increase in the incidence of IE is due to a significant increase in the number of cardiac surgery, surgery and post-injection abscesses. It is believed that the likelihood of septic endocarditis in people using non-sterile syringes (for example, in drug addiction) is 30 times higher than in healthy people.

Classification of endocarditis

A. According to the course of the disease

• acute - from several days to 2 weeks;
• subacute infective endocarditis;
• chronic relapsing course.

B. By the nature of the lesion of the valvular apparatus

• primary infective endocarditis (Chernogubov form), which occurs on unchanged heart valves;
• secondary endocarditis - develops against the background existing pathology heart valves or large vessels (including in patients with artificial valves).

B. According to the etiological factor

• streptococcal,
• staphylococcal,
• enterococcal,
• viral,
• other

When making a diagnosis, take into account: diagnostic status - ECG with a typical picture; process activity - active, persistent or repeated; pathogenesis - IE of own valves; Prosthetic valve IE, IE in drug addicts. Localization of IE: with damage to the aortic or mitral valve of the tricuspid valve, with damage to the pulmonary valve; with parietal localization of vegetations.

Causes and pathogenesis of endocarditis

The causative agents of infective endocarditis are gram-positive and gram-negative bacteria (strepto- and staphylococci, enterococci, Escherichia and Pseudomonas aeruginosa, Proteus), less often fungi, rickettsia, chlamydia, viruses.

Transient bacteremia is noted as various infections(sinusitis, sinusitis, cystitis, urethritis, etc.), and after a large number diagnostic and medical procedures during which the epithelium colonized by various microbes is damaged. Important role in the development of infective endocarditis plays a decrease in immunity due to concomitant diseases, elderly age, immunosuppressant therapy, etc.

Symptoms of infective endocarditis

The clinical manifestations of IE are varied. In acute endocarditis of streptococcal and staphylococcal etiology, symptoms such as a sudden pronounced increase in body temperature, severe chills, signs acute insufficiency damaged valves and heart failure. Acute endocarditis is considered as a complication of general sepsis.

The disease lasts up to 6 weeks from the onset of the disease, characterized by rapid destruction and perforation of the valve leaflets, multiple thromboembolism, progressive heart failure. With untimely surgical intervention, IE quickly leads to death.

Subacute infective endocarditis often develops at the age of 35-55 years and older. Symptoms of the disease usually appear 1-2 weeks after bacteremia.

Initially, symptoms of intoxication are observed: fever, chills, weakness, night sweats, fatigue, weight loss, arthralgia, myalgia. The disease can proceed in the form of "repeated acute respiratory infections" with short courses of antibiotic treatment.

With a long severe course Diseases in some patients reveal the following characteristic symptoms:

• Janeway's symptom (Janeway's spots or rashes) is one of the extracardiac manifestations of infective endocarditis: an immunoinflammatory reaction in the form of red spots (ecchymosis) up to 1-4 mm in size on the soles and palms.

• Osler's nodules - also a symptom of septic endocarditis - are red painful lumps(nodules) in the subcutaneous tissue or skin.

• Petechial rashes in septic endocarditis are often found on the mucous membranes of the mouth, conjunctiva and eyelid folds - a symptom of Lukin-Libman.

• The symptom of "drum sticks" and "watch glasses" is a thickening of the distal phalanges of the fingers and the appearance of a convex shape of the nails.

• Roth spots - hemorrhages in the fundus with an intact center - not a pathognomonic symptom.
• In patients with infective endocarditis, a pinch symptom (Hecht's symptom) or a tourniquet symptom (Konchalovsky-Rumpel-Leede symptom) are usually positive: when squeezing the skin fold with the fingers or pulling the limb with a tourniquet, hemorrhages appear in this area.

Perhaps the development of glomerulonephritis, arthritis, myocarditis, thromboembolic complications.

There are variants of the course of infective endocarditis without fever, with damage to any one organ - nephropathy, anemia.

The presence of endocarditis should be suspected with a newly appeared noise over the region of the heart, embolism of the cerebral and renal arteries; septicemia, glomerulonephritis and suspected kidney infarction; fever with the presence of prosthetic heart valves; first developed ventricular disorders rhythm; typical manifestations on the skin; multiple or "flying" infiltrates in the lungs, peripheral abscesses unclear etiology. Combination of fever and disturbance cerebral circulation in a young patient is considered a manifestation of infective endocarditis until another etiology of the disease is proven.

Diagnosis of endocarditis

History and physical examination. It is necessary to ask the patient about existing heart defects, surgical interventions on the heart valves during the last 2 months; rheumatic fever, endocarditis in history; transferred infectious diseases in the last 3 months; pay attention to skin manifestations - pallor (signs of anemia), ecchymosis.

Ophthalmic manifestations - Roth spots (retinal hemorrhages with a white center, Lukin-Libman spots (petechiae on the transitional fold of the conjunctiva); transient, often unilateral blindness or impaired visual fields.

The most important sign of infective endocarditis is the appearance or change in the nature of murmurs in the heart as a result of damage to the heart valves.

In the formation of aortic defect - first systolic murmur at the left edge of the sternum and at the V point (Botkin-Erb point), as a result of stenosis of the aortic orifice due to vegetations on the semilunar valves, then signs appear aortic insufficiency- gentle protodiastolic murmur over the aorta and at the V point, aggravated in the standing position and lying on the left side. As the valves are destroyed, the intensity of the diastolic murmur increases, the II tone on the aorta weakens.

Symptoms of CNS damage are manifested in the form of confusion, delirium, paresis and paralysis as a result of thromboembolism, meningoencephalitis.

In acute infective endocarditis, signs of severe heart failure are detected - bilateral moist rales, tachycardia, additional third heart sound, edema lower extremities.

In half of the patients - spleno- or hepatomegaly, it is often possible to notice icterus of the sclera and slight yellowness of the skin; lymphadenopathy. Perhaps the development of thromboembolic infarcts of various organs (lungs, myocardium, kidneys, spleen).

Widespread myalgias and arthralgias are observed in 30-40% of cases, with predominant involvement of the shoulder, knee and sometimes small joints of the hands and feet. Myositis, tendinitis and enthesopathy, septic mono- or oligoarthritis of various localization are rare.

Laboratory and instrumental studies:

general analysis blood in acute infective endocarditis - normochromic normocytic anemia, with a shift of the leukocyte formula to the left, thrombocytopenia (20% of cases), accelerated ESR.

AT biochemical analysis blood dysproteinemia with an increase in the level of gamma globulins, an increase in CRH by 35-50%.

Urinalysis: macro- and microscopic hematuria, proteinuria, with the development of streptococcal glomerulonephritis - erythrocyte cylinders.

Blood culture is an objective confirmation of the infectious nature of endocarditis when a pathogen is detected, it allows you to determine the sensitivity of an infectious agent to antibiotics.

In 5-31% of cases with IE, a negative result is possible. Serological methods are effective in IE.

ECG - against the background of IE with myocarditis or myocardial abscess - conduction disturbance, less often paroxysms of atrial tachycardia or atrial fibrillation.

Echocardiography is performed for all patients with suspected IE no later than 12 hours after the initial examination of the patient. Transesophageal echocardiography is more sensitive to detect vegetation than transthoracic echocardiography, but is more invasive.

Chest x-ray - with infective endocarditis of the right heart, multiple or "flying" infiltrates in the lungs are observed.

Diagnostic criteria for infective endocarditis

The diagnosis of infective endocarditis is based on modified criteria developed by the Duke University Endocarditis Service:

1) positive blood culture;

2) evidence of endocardial damage - data from transthoracic echocardiography - fresh vegetation on the valve, or its supporting structures, or implanted material.

Differential diagnosis of infective endocarditis

Held with:

• acute rheumatic fever,
• systemic lupus erythematosus,
• nonspecific aortoarteritis,
• exacerbation of chronic pyelonephritis,
• some other diseases

Treatment of endocarditis

Treatment goals: elimination of the pathogen, prevention of complications.

Indications for hospitalization: patients without complications and stable hemodynamics - in general wards; patients with severe heart failure and complications - to the intensive care unit.

Medical treatment

Antimicrobial therapy is started immediately after diagnosis. Apply bactericidal antibiotics, which are administered parenterally. With an unknown pathogen, high-dose empiric antibiotic therapy is carried out. All patients with proven streptococcal etiology should be treated in a hospital for at least 2 weeks.

Infective endocarditis caused by Streptococcus viridans, with damage to its own valves:

Benzylpenicillin (sodium salt) IV or IM 12-20 million units 4-6 r/day, 4 weeks, or gentamicin 3 mg/kg per day (no more than 240 mg/day) 2-3 r/day ; ceftriaxone IV or IM 2 g/day 1 r/day, 4 weeks This therapy allows clinical and bacteriological remission in 98% of cases of IE.

Dosage of gentamicin in mg/kg in obese patients will create more high concentration in serum than in lean patients. Relative contraindications to the use of gentamicin are patients over 65 years of age, renal failure, neuritis of the auditory nerve.

Alternative antibiotics are:

Amoxicillin / clavulanic acid IV or IM 1.2-2.4 g 3-4 r / day, 4 weeks or Ampicillin / sulbactam iv or IM 2 g 3-4 r / day, 4 weeks

Vancomycin is the drug of choice in patients with penicillin and other lactam allergies. With prolonged intravenous use of vancomycin, fever, allergic rash, anemia, thrombocytopenia. It has oto- and nephro-toxicity.

Infective endocarditis due to Staphylococcus aureus:

Oxacillin iv or IM 2 g 6 r / day, 4-6 weeks + gentamicin iv or IM 3 mg / kg 1-3 r / day (add at the discretion of the doctor for 3-5 days ), 4-6 weeks; or cefazolin or cephalothin iv or IM 2 g 3-4 r/day, 4-6 weeks + gentamicin iv or IM 3 mg/kg 1-3 r/day, 4-6 weeks ; or cefotaxime iv or IM 2 g 3 r / day, 4-6 weeks + gentamicin iv or IM 3 mg / kg 1-3 r / day (add at the discretion of the doctor for 3-5 days), 4-6 weeks; or imipenem / cilastatin IV or IM 0.5 g 4 r / day, 4-6 weeks; or meropenem intravenously or intramuscularly, 1 g 3 r / day, 4-6 weeks; or vancomidin IV or IM 1 g 2 r / day, 4-6 weeks; or rifampicin inside 0.3 g 3 r / day, 4-6 weeks.

Penicillin is indicated for sensitive S. aureus as an alternative medicinal product: benzylpenicillin (sodium salt) IV, 4 million units 6 r / day, 4-6 weeks.

Treatment in identifying methicillin-resistant strains of staphylococci. As a rule, they are resistant to cephalosporins and carbapenems, so the appointment of these drugs is not advisable: vancomidine 1 g 2 times a day, 4-6 weeks; linezolid i.v. 0.6 g 2 r / day, 4-6 weeks. Linezolid is characterized by high bioavailability, reaching 100%, and good absorption from the gastrointestinal tract, suitable for gradual antimicrobial therapy: initiation of treatment with intravenous infusion with subsequent transition to oral forms of drugs.

Treatment of infective endocarditis caused by methicillin-susceptible staphylococcus within 1 year after valve replacement surgery:

Oxacillin IV 2 g 6 r / day, 4-6 weeks + gentamicin iv 3 mg / kg 1-3 r / day, 2 weeks, + rifampicin IV 0.3 g 2 r / day (can be administered orally), 4-6 weeks. In the presence of an allergy to penicillin, oxacillin can be replaced with cephalosporins or vancomycin.

With the ineffectiveness of adequate antibiotic therapy for a week, with severe violations hemodynamics and the development of refractory heart failure, the formation of a myocardial abscess or valve ring, cardiosurgical treatment is indicated - removal of the affected valve with its subsequent prosthetics.

Prognosis for endocarditis

With timely antibiotic therapy, the prognosis is quite favorable. Fungal infective endocarditis has a mortality rate of 80% or more. In the case of chronic heart failure - mortality is more than 50% in the next 5 years.

Prevention of endocarditis

Antibiotics should be given to high- and intermediate-risk patients: prosthetic heart valve, hemodialysis, complex congenital heart disease, surgical vascular conduits, history of infective endocarditis, mitral valve prolapse, corticosteroid and cytotoxic therapy, infection intravenous catheter, surgical interventions and post-injection abscesses.

Endocarditis: causes, symptoms, course, therapy of various types

Endocarditis - a disease that affects the inner lining of the heart, as well as the aortic and heart valves. This is a serious, life-threatening pathology, characterized by rapid development, the danger of embolism of blood vessels, internal vital important organs and the development of immunopathological processes.

Endocarditis is divided into infectious (bacterial) and non-infectious. Although in the vast majority of cases endocarditis is infectious nature, there are pathologies that develop as a reaction to metabolic changes within the framework of the immunopathological process or during mechanical damage hearts.

Non-infectious endocarditis includes:

• Atypical warty endocarditis with;
• Rheumatic endocarditis;
• Endocarditis in rheumatoid, reactive arthritis;
• Fibroplastic endocarditis of Leffer;
• Non-bacterial thrombotic endocarditis.

Almost always, the above diseases are an indicator that the risk of developing infective endocarditis (IE) in these cases is extremely high, namely, it represents greatest danger for the life of the patient.

Causes of infective endocarditis

The disease is rare, but recent times there is a steady trend towards an increase in the incidence of IE, which is associated with an increase in resistance (resistance) bacterial microflora to antibiotics as a result of mutations. Another reason for the increase in the incidence of septic endocarditis is the increase in the number of people taking intravenous drugs.

Most often, the causative agents of this disease are pathogenic gram-positive microorganisms: in most cases, these are staphylococcal, streptococcal, enterococcal infections. Much less often, its development is provoked by other microorganisms, among which there may be gram-negative bacteria, rare atypical pathogens and fungal infections.

The defeat of the heart membrane in IE occurs with bacteremia. Synonymous with the concept of "infective endocarditis" are such definitions as septic or bacterial endocarditis. Bacteremia (the presence of bacteria in the blood) can develop when favorable conditions even after the most harmless procedures.

Procedures with a high risk of developing bacteremia are:

1. Dental operations with damage to the mucous membranes of the oral cavity and gums;
2. Performing bronchoscopy using rigid instruments;
3. Cystoscopy, manipulations and surgical interventions on the organs of the urinary system, if there is an infectious component;
4. Conducted biopsy of the urinary tract or prostate gland;
5. Operation on the prostate gland;
6. Adenoidectomy, tonsillectomy (removal of tonsils and adenoids);
7. Operations performed on the biliary tract;
8. Previously performed lithotripsy (destruction of stones in the kidneys, urinary, gallbladder);
9. Gynecological operations.

Cardiologists identify risk groups that have prerequisites for inflammation of the endocardium, for which it is necessary antimicrobial therapy for the prevention of endocarditis.

The high risk group includes:

• Patients who have previously had bacterial endocarditis;
• Operated for heart valve replacement if mechanical or biological materials were used;
• Having congenital and acquired complex with disorders related to the aorta, cardiac ventricles - the so-called "blue" defects;

The following categories of patients are at moderate risk:

• Patients with;
• With hypertrophic;
• Having all other heart defects (congenital and acquired), not falling into the first risk group, without cyanosis.

Patients with the following diagnoses are less at risk of developing this disease:

• and vessels;
• Defect of the interatrial and interventricular septum, including operated, up to six months after surgery;
• Implanted pacemakers and defibrillators;
• no valve damage.

Video: Endocarditis. Why is it important to treat your teeth on time?

How does IE develop?

The period from the penetration of the infection to the development of the IE clinic varies from several days to several months. It depends on the virulence of the pathogen, the state of the patient's immune system and the heart.

Inside the cavity of the heart, the pathogen settles on the valve leaflets and begins to grow, with the formation of colonies of microorganisms (vegetation). In addition to microorganisms, they contain erythrocytes, leukocytes, platelets, fibrin. As the infection progresses, the surface of the valves becomes deformed, forming a bumpy surface or ulcers with thrombotic overlay.

When the deformation reaches a significant size, heart valves lose their ability to close tightly, which leads to the development of hemodynamic disorders and the occurrence of acute heart failure. This condition develops rapidly and poses a danger to the life of the patient. Destroyed pieces of valves, fragments of colonies of microorganisms can come off from the destroyed valve. With the blood flow, they are carried along the small and big circle blood circulation, can cause ischemia of important organs and, which is accompanied by various neurological disorders, paresis and paralysis and other serious complications.

Classification of endocarditis

When making a diagnosis, the doctor must formulate a refined diagnosis that characterizes the main features inherent in this type of disease, which allows a more accurate and detailed idea of ​​the course of the disease.

1. According to the activity of the pathological process, active, cured, recurrent endocarditis is distinguished;
2. According to the probability and certainty of the diagnosis (probable or definite);
3. Type infectious agent(defined or not established);
4. By the nature of the affected valve, if prosthetics take place.

Several types of flow and severity of the inflammatory process are also distinguished, taking into account the initial characteristics of damaged valves.

• Acute septic endocarditis can develop within hours or days, it is characterized by severe hectic fever, rapid development of complications in cardiovascular system. Acute IE is distinguished by a pronounced ability to penetrate into the surrounding tissues, which is due to the type of pathogen with high level virulence;
• Subacute infective endocarditis develops more slowly, from the penetration of the pathogen into the heart cavity to clinical manifestations lasts from several weeks to several months. Its course is more favorable, since its pathogen is less aggressive and capable of penetrating the surrounding tissues.

In addition, the disease is classified into the following types:

1. Primary IE - initially intact endocardium is affected;
2. Secondary IE - can develop against the background of existing heart disease.
3. The so-called "prosthetic" IE - develops when an artificial heart valve becomes infected.

IE in children, symptoms

In children younger age, from the neonatal period to 2 years, possible development of congenital IE. As the cause of this disease are infectious diseases of the mother or intrauterine infection fetus. Perhaps the development of acquired endocarditis in children, as a complication of meningococcal infection, salmonellosis, brucellosis, scarlet fever, HIV. More often in children, the aortic valve is affected, inflammation leads to destructive changes, perforation, rupture of the valves. The course of this disease is difficult for children to endure, the risk of complications and death is high.

Signs and methods of diagnosing IE

Septic endocarditis begins acutely. Suddenly, the body temperature rises to 39-40 C, there is a strong chill, pain in the muscles and joints. The mucous membranes and skin turn pale, small rashes appear on it (hemorrhagic rash), there are nodular rashes on the soles of the feet and palms of a crimson hue (Osper's nodules), disappearing a few days after the onset of the disease. If an infection joins, then the rashes suppurate, and later they scar. To nail phalanges the fingers of the upper and lower extremities thicken, they take characteristic appearance, known as " Drumsticks", and nails -" watch glasses. There may be hemorrhages under the nails in the form of reddish-brown stripes.

When listening to heart sounds, extraneous noises are clearly defined, having different tones and loudness, depending on the degree of damage to the valves, heart failure is often diagnosed at the same time.

If the right parts of the heart are affected and developed pulmonary infarction, development of pleurisy, hemoptysis and pulmonary edema can be observed. Almost always, patients have kidney damage in the form of nephritis, there is a risk of developing renal failure. No less often develops damage to the spleen, liver with the development of hepatitis, abscess or liver infarction. In some cases, eye damage occurs that can lead to blindness. Often there are manifestations of arthralgia, with the development of periostitis, hemorrhage and embolism of the vessels of the periosteum, patients complain of pain in the bones.

These are classic signs of endocarditis, but sometimes they are modified or partially absent. To clarify the diagnosis, it is necessary to identify the presence of a pathogenic microorganism in the blood, for which arterial blood is examined by laboratory methods. Vegetations of microorganisms on the heart valve can be detected using. Often, at the initial stage of the disease, endocarditis cannot be recognized, since such or similar symptoms may accompany other acute infectious diseases.

figure: signs and complications of endocarditis

If IE is suspected, the doctor should evaluate all the signs of the disease together. If the first blood culture did not give a positive result, it is repeated, repeatedly. Also, if this disease is suspected, an echocardiogram should be prescribed, since this is the most informative method, allowing to detect and visualize the pathology of the heart valve and the growth of microorganisms. During the course of treatment with using echocardiography monitor the effectiveness of the therapy. In some cases, according to indications, a diagnostic biopsy of the endocardium is performed in order to confirm the diagnosis.

• Biochemical and general blood tests confirm the ongoing inflammatory process in the body;
• Chest x-ray determines changes in the lungs with;
• Ultrasound of the heart allows you to visually determine the presence of IE and describe it in detail.

Video: infective endocarditis on echocardiography

In the video: infective endocarditis of the tricuspid valve, vegetation. Echocardiography, apical access.

Treatment for infective and nonspecific endocarditis

After confirming the diagnosis of IE doctor prescribes massive antibiotic therapy The patient is given antibiotics large doses intravenously. After determining the pathogen, it is necessary to choose the most effective drug capable of suppressing pathogenic microorganisms, for this, the endocarditis pathogen is cultured in a sterile environment in the laboratory and exposed to several drugs. Treatment for endocarditis is carried out for a long time, for 1.5-2 months until the infection is completely destroyed, which must be confirmed repeatedly. microbiological analysis blood, control over the patient's condition, echocardiography data, ultrasound and other diagnostic methods.

Fungal endocarditis is more difficult to treat. Most often, they are detected in weakened patients with depressed immunity, who previously received long-term ineffective antibacterial treatment; in patients with chronic systemic diseases: malignant tumors, HIV infection, . In severe heart failure, a decision may be made to surgical intervention on the heart and excision of microbial growths.

When appointed antibacterial treatment acute manifestations diseases may subside, however, if microorganisms are resistant to antibiotics, they are able to become covered with a protective film under which the infection persists. This period can last for a long time, if suitable conditions the film is destroyed, the microorganisms are activated again, which causes a relapse of the disease within 2-3 weeks after the end of treatment.

At the same time, symptomatic therapy is carried out to maintain the patient's cardiac activity, relieve intoxication phenomena, and prevent the formation of blood clots. All activities should be carried out with constant monitoring of blood composition in order to see the dynamics of the disease in time.

If valvular disease occurs during IE, life threatening heart failure, vascular embolism, the occurrence of foci of infection outside the valve ring, doctors may decide on the need for surgical operation during the active phase of the disease, in order to save the patient's life. During surgery, surgeons correct the defect of the valves, sutured the torn leaflets. With the complete destruction of the valves, they can be carried out.

Photo: mitral valve replacement

In the treatment of non-infectious endocarditis, great attention should be paid to the treatment of the underlying disease.. To eliminate vegetations, anticoagulant drugs are prescribed that contribute to their disappearance.

What is the prognosis for endocarditis?

Until recently, until antibiotic and chemotherapy therapy was introduced into practice, the prognosis for this disease was extremely unfavorable, there was a high mortality rate among patients, and cases of recovery were isolated. Currently, the prognosis depends on many related factors.

With a favorable set of circumstances, from 55 to 85% of all patients are cured with this diagnosis. To a greater extent, the course of the disease and the prognosis depend on the aggressiveness and pathogenicity of the infectious agent and the susceptibility to infection of the patient himself.

Regardless of the severity past illness, endocarditis in most cases affects the entire future life of a person, since in the future there will always be a risk of developing heart valve disease and related complications. These include the development of myocarditis - inflammation of the middle layer of the heart muscle, which carries even more severe consequences because it can lead to the development of cardiomyopathy, rapid development heart failure and arrhythmias. This condition may require additional symptomatic therapy. Great danger represents renal failure and the resulting intoxication of the body.

Disease prevention

In order to minimize the risk of developing this formidable disease, one should adhere to simple rules and take care of your health:

1. It is necessary to sanitize the foci of infections in the body in a timely manner, treat caries, diseases of the nasopharynx. It is necessary to be attentive even to the most common chronic diseases - tonsillitis, sinusitis, rhinitis; acute and chronic kidney diseases require special attention and attention.
2. After surgical interventions in persons at risk, it is necessary to carry out antibacterial therapy for prophylactic purposes. Operations include all dental procedures, including manipulations on the gums with a violation of the oral mucosa.
3. Stressful situations, excessive physical and psychological stress, acute viral infections should be avoided;
4. After infective endocarditis, patients should be on a permanent dispensary record with a cardiologist, take courses in a timely manner rehabilitation therapy in sanatoriums;
5. You need to purposefully strengthen your immunity, for this you need to fully eat, lead healthy lifestyle life and regularly take multivitamins;
6. Timely immunization against mumps, measles, rubella viruses is of great benefit in preventing the development of complications;

Patients with infective endocarditis should carefully monitor their health throughout their lives, then they will be able to conduct a full-fledged, active image life without fear of recurrence of the disease.

Video: lecture on infective endocarditis