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CardioNerds (Drs. Amit Goyal, Matthew Delfiner, and Tiffany Dong) discuss infective endocarditis with distinguished clinician-educator Dr. Michael Cullen. We dive into the nuances of infective endocarditis, including native valve endocarditis, prosthetic valve endocarditis, and right-sided endocarditis.\n\n\n\nNotes were drafted by Dr. Tiffany Dong, and audio editing was performed by student Dr. Adriana Mares.\n\n\n\nThe CardioNerds Beyond the Boards Series was inspired by the Mayo Clinic Cardiovascular Board Review Course and designed in collaboration with the course directors Dr. Amy Pollak, Dr. Jeffrey Geske, and Dr. Michael Cullen.\n\n\n\n\n\n\n\n\n\nCardioNerds Beyond the Boards SeriesCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll\n\n\n\n\n\nCardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron!\n\n\n\n\n\n\n\n\n\nPearls and Quotes\n\n\n\n\nThe physical exam is crucial in the evaluation of infective endocarditis and includes cardiac auscultation and a search for sequelae of endocarditis, such as immunologic and embolic phenomena.\n\n\n\nThe modified Duke Criteria categorizes the diagnosis of infective endocarditis into four different buckets: definite endocarditis by pathology, definite endocarditis by clinical criteria, possible endocarditis, and rejected.\n\n\n\nThe diagnosis of endocarditis may involve several different imaging modalities, including transthoracic echocardiogram, transesophageal echocardiogram, 4D CT, and nuclear imaging.\n\n\n\nFor left-sided endocarditis, indications to operate include endocarditis due to S. aureus or fungi, heart failure, evidence of perivalvular complications, persistent bacteremia, and large vegetations.\n\n\n\nThe management of endocarditis often involves multiple teams, including cardiology, infectious disease, addiction medicine, neurology, anesthesiology, and cardiothoracic surgery.\n\n\n\n\nNotes \n\n\n\nWhat signs/complications of endocarditis are apparent on physical exam and labs?\n\n\n\n\nA new or worsening cardiac murmur with possible signs of volume overload.\n\n\n\nVascular phenomena encompass splinter hemorrhages, conjunctival hemorrhages, Janeway lesions, mycotic aneurysms, and TIA/strokes.\n\n\n\nImmunologic phenomena include glomerulonephritis, Roth spots, and Osler nodes.\n\n\n\nPositive blood cultures with 2-3 samples collected.\n\n\n\nElevated inflammatory markers.\n\n\n\n\nHow does the modified Duke criteria assist in the diagnosis of infective endocarditis?\n\n\n\n\nThe modified Duke criteria separate the diagnosis of endocarditis into four categories: definite endocarditis by pathology, definite endocarditis by clinical criteria, possible endocarditis, and rejected endocarditis.\n\n\n\nDefinitive endocarditis by pathology requires pathologic confirmation of \u201cbugs under the microscope.\u201d\n\n\n\nDefinitive endocarditis by clinical criteria requires two major criteria, one major and two minor criteria, or all five minor criteria.\n\n\n\nPossible endocarditis requires one major and one minor or three minor criteria.\n\n\n\nMajor criteria:Positive blood culture for typical organism\n\nEvidence of endocardial involvement (e.g., vegetation on echo)\n\n\n\n\n\nMinor CriteriaPredisposing clinical factors (e.g., intravenous drug use, known valvulopathy)FeverImmunologic phenomenaVascular phenomena\n\nBlood culture for atypical organism\n\n\n\n\n\n\nWhat is the role of TTE compared to TEE in endocarditis?\n\n\n\n\nTTE and TEE both have their roles in the workup for endocarditis.\n\n\n\nTTE can provide a baseline screen and yield a better understanding of ventricular size and function than transesophageal.\n\n\n\nThe strength of TEE is the ability to visualize smaller vegetations along with perivalvular complications that may be missed on TTE.\n\n\n\nIf clinical suspicion is high for endocarditis, repeat echocardiography is warranted.\n\n\n\n\nWhat are other tools to evaluate for endocarditis in prosthetic valves?\n\n\n\n\nTTE and TEE remain important and should be commonly utilized for the diagnosis of endocarditis.