Endocarditis, Overview, Complications and Cure

What Is Endocarditis?

Endocarditis is an infection of the inner lining of the heart chambers and valves. This lining is called the endocardium. The condition also is called infective endocarditis (IE).

The term “endocarditis” also is used to describe an inflammation of the endocardium due to other conditions. This article only discusses endocarditis related to infection.

IE occurs if bacteria, fungi, or other germs invade your bloodstream and attach to abnormal areas of your heart. The infection can damage your heart and cause serious and sometimes fatal complications.

IE can develop quickly or slowly; it depends on what type of germ is causing it and whether you have an underlying heart problem. When IE develops quickly, it’s called acute infective endocarditis. When it develops slowly, it’s called subacute infective endocarditis.

Overview

IE mainly affects people who have:

• Damaged or artificial (man-made) heart valves
• Congenital heart defects (defects present at birth)
• Implanted medical devices in the heart or blood vessels

People who have normal heart valves also can have IE. However, the condition is much more common in people who have abnormal hearts.

Certain factors make it easier for bacteria to enter your bloodstream. These factors put you at higher risk for IE. For example, poor dental hygiene and unhealthy teeth and gums increase your risk for the infection.

Other risk factors include using intravenous (IV) drugs, having a catheter (tube) or another medical device in your body for long periods, and having a history of IE.

Common symptoms of IE are fever and other flu-like symptoms. Because the infection can affect people in different ways, the signs and symptoms vary. IE also can cause problems in many other parts of the body besides the heart.

If you’re at high risk for IE, seek medical care if you have signs or symptoms of the infection, especially a fever that persists or unexplained fatigue (tiredness).

Outlook

IE is treated with antibiotics for several weeks. You also may need surgery to repair or replace heart valves or remove infected heart tissue.

Most people who are treated with the proper antibiotics recover. But if the infection isn’t treated, or if it persists despite treatment (for example, if the bacteria are resistant to antibiotics), it’s usually fatal.

If you have signs or symptoms of IE, see your doctor as soon as you can, especially if you have abnormal heart valves.

What Causes Endocarditis?

Infective endocarditis (IE) occurs if bacteria, fungi, or other germs invade your bloodstream and attach to abnormal areas of your heart. Certain factors increase the risk of this happening.

A common underlying factor in IE is a structural heart defect, especially faulty heart valves. Usually your immune system will kill germs in your bloodstream. However, if your heart has a rough lining or abnormal valves, the invading germs can attach and multiply in the heart.

Other factors also can play a role in causing IE. Common activities, such as brushing your teeth or having certain dental procedures, can allow bacteria to enter your bloodstream. This is even more likely to happen if your teeth and gums are in poor condition.

Having a catheter (tube) or another medical device inserted through your skin, especially for long periods, also can allow bacteria to enter your bloodstream. People who use intravenous (IV) drugs also are at risk for IE because of the germs on needles and syringes.

Bacteria also may spread to the blood and heart from infections in other parts of the body, such as the gut, skin, or genitals.

Endocarditis Complications

As the bacteria or other germs multiply in your heart, they form clumps with other cells and matter found in the blood. These clumps are called vegetations (vej-eh-TA-shuns).

As IE worsens, pieces of the vegetations can break off and travel to almost any other organ or tissue in the body. There, the pieces can block blood flow or cause a new infection. As a result, IE can cause a range of complications.

Heart Complications

Heart problems are the most common complication of IE. They occur in one-third to one-half of all people who have the infection. These problems may include a new heart, heart failure, heart valve damage, heart block, or, rarely, a heart attack.

Central Nervous System Complications

These complications occur in as many as 20 to 40 percent of people who have IE. Central nervous system complications most often occur when bits of the vegetation, called emboli (EM-bo-li), break away and lodge in the brain.

The emboli can cause local infections called brain abscesses. Or, they can cause a more widespread brain infection called meningitis.

Emboli also can cause strokes or seizures. This happens if they block blood vessels or affect the brain’s electrical signals. These complications can cause long-term damage to the brain and may even be fatal.

Complications in Other Organs

IE also can affect other organs in the body, such as the lungs, kidneys, and spleen.

Lungs. The lungs are especially at risk when IE affects the right side of the heart. This is called right-sided infective endocarditis.

A vegetation or blood clot going to the lungs can cause a pulmonary embolism (PE) and lung damage. A PE is a sudden blockage in a lung artery.

Other lung complications include pneumonia and a buildup of fluid or pus around the lungs.

Kidneys. IE can cause kidney abscesses and kidney damage. The infection also can inflame the internal filtering structures of the kidneys.

Signs and symptoms of kidney complications include back or side pain, blood in the urine, or a change in the color or amount of urine. In some cases, IE can cause kidney failure.

Spleen. The spleen is an organ located in the left upper part of the abdomen near the stomach. In some people who have IE, the spleen enlarges (especially in people who have long-term IE). Sometimes emboli also can damage the spleen.

Signs and symptoms of spleen problems include pain or discomfort in the upper left abdomen and/or left shoulder, a feeling of fullness or the inability to eat large meals, and hiccups.

Patent Ductus Arteriosus: Overview and Outlook

Patent ductus arteriosus (PDA) is a heart problem that affects some babies soon after birth. In PDA, abnormal blood flow occurs between two of the major arteries connected to the heart. These arteries are the aorta and the pulmonary artery.

Before birth, these arteries are connected by a blood vessel called the ductus arteriosus. This blood vessel is a vital part of fetal blood circulation.

Within minutes or up to a few days after birth, the ductus arteriosus closes. This change is normal in newborns.

In some babies, however, the ductus arteriosus remains open (patent). The opening allows oxygen-rich blood from the aorta to mix with oxygen-poor blood from the pulmonary artery. This can strain the heart and increase blood pressure in the lung arteries.

Figure A shows a cross-section of a normal heart. The arrows show the direction of blood flow through the heart. Figure B shows a heart with patent ductus arteriosus. The defect connects the aorta and the pulmonary artery. This allows oxygen-rich blood from the aorta to mix with oxygen-poor blood in the pulmonary artery.

Overview

PDA is a type of congenital heart defect. A congenital heart defect is any type of heart problem that’s present at birth.

If your baby has a PDA but an otherwise normal heart, the PDA may shrink and go away. However, some children need treatment to close their PDAs.

Some children who have PDAs are given medicine to keep the ductus arteriosus open. For example, this may be done if a child is born with another heart defect that decreases blood flow to the lungs or the rest of the body.

Keeping the PDA open helps maintain blood flow and oxygen levels until doctors can do surgery to correct the other heart defect.

Outlook

PDA is a fairly common congenital heart defect. Although the condition can affect full-term infants, it’s more common in premature infants.

On average, PDA occurs in about 8 out of every 1,000 premature babies, compared with 2 out of every 1,000 full-term babies. Premature babies also are more vulnerable to the effects of PDA.

PDA is twice as common in girls as it is in boys.

Doctors treat the condition with medicines, catheter-based procedures, and surgery. Most children who have PDAs live healthy, normal lives after treatment.

What Is a Heart Murmur?

A heart murmur is an extra or unusual sound heard during a heartbeat. Murmurs range from very faint to very loud. Sometimes they sound like a whooshing or swishing noise.

Normal heartbeats make a “lub-DUPP” or “lub-DUB” sound. This is the sound of the heart valves closing as blood moves through the heart. Doctors can hear these sounds and heart murmurs using a stethoscope.

Overview

The two types of heart murmurs are innocent (harmless) and abnormal.

Innocent heart murmurs aren’t caused by heart problems. These murmurs are common in healthy children. Many children will have heart murmurs heard by their doctors at some point in their lives.

People who have abnormal heart murmurs may have signs or symptoms of heart problems. Most abnormal murmurs in children are caused by congenital heart defects. These defects are problems with the heart’s structure that are present at birth.

In adults, abnormal heart murmurs most often are caused by acquired heart valve disease. This is heart valve disease that develops as the result of another condition. Infections, diseases, and aging can cause heart valve disease.

Outlook

A heart murmur isn’t a disease, and most murmurs are harmless. Innocent murmurs don’t cause symptoms. Having one doesn’t require you to limit your physical activity or do anything else special. Although you may have an innocent murmur throughout your life, you won’t need treatment for it.

The outlook and treatment for abnormal heart murmurs depend on the type and severity of the heart problem causing them.

What Are Congenital Heart Defects?

Congenital heart defects are problems with the heart’s structure that are present at birth. These defects can involve:

• The interior walls of the heart
• The valves inside the heart
• The arteries and veins that carry blood to the heart or the body

Congenital heart defects change the normal flow of blood through the heart.

There are many types of congenital heart defects. They range from simple defects with no symptoms to complex defects with severe, life-threatening symptoms.

Congenital heart defects are the most common type of birth defect. They affect 8 out of every 1,000 newborns.

Many of these defects are simple conditions. They need no treatment or are easily fixed. Some babies are born with complex congenital heart defects. These defects require special medical care soon after birth.

The diagnosis and treatment of complex heart defects has greatly improved over the past few decades. As a result, almost all children who have complex heart defects survive to adulthood and can live active, productive lives.

Most people who have complex heart defects continue to need special heart care throughout their lives. They may need to pay special attention to how their condition affects issues such as health insurance, employment, birth control and pregnancy, and other health issues.

In India, more than 1 million adults are living with congenital heart defects.

Heart Transplant – facts

What is a Heart Transplant?

Heart transplant is a simple three step procedure. This is a rather simple procedure for a cardiac surgeon compared to other complicated surgeries.

First Step:

Harvesting organ from the donor:

The donor is usually a brain dead person on life support. When the family of such a person is willing to donate the organ, the organ is removed and protected in ice to prevent any damage. A heart once removed from the body stays stable for about 6 hours. Due to time constraints the Heart is usually flown down if the transplant has to be conducted interstate. The Tamil Nadu police offer support in such cases if the Heart has to be taken from one part of the city to the other. The areas are cordoned off immediately on request. Procuring a heart itself is a very structured and transparent process with the help of the government. The heart usually goes to such a recipient who needs it most.

Removing the recipient’s damaged heart:

The second step is removing the damaged heart. This is a very simple procedure if the recipient has not undergone any previous surgeries. In case the recipient has undergone a Bypass or a catheter implant then cutting through the scar tissue may prolong or complicate this step.

Implantation of the donor heart: The third step is probably the easiest; the implantation of the donor heart. Today, this operation basically involves the creation of only five lines of stitches, or “anastomoses”. These suture lines connect the large blood vessels entering and leaving the heart. Remarkably, if there are no complications, most patients who have had a heart transplant are home about one week after the surgery. The generosity of donors and their families makes organ transplant possible.

Who needs a Heart transplant?

Most patients require a transplant because their hearts can no longer pump well enough to supply blood with oxygen and nutrients to the organs of the body. A smaller number of patients have a good pump, but a bad “electrical conduction system” of the heart. This electrical system determines the rate, rhythm and sequence of contraction of the heart muscle. There are all kinds of problems that can occur with the conduction system, including complete interruption of cardiac function causing sudden cardiac death.

While there are many people with “end-stage” heart disease with inadequate function of the heart, not all qualify for a heart transplant. All the other important organs in the body must be in pretty good shape. Transplants cannot be performed in patients with active infection, cancer, or bad diabetes mellitus; patients who smoke or abuse alcohol are also not good candidates. It’s not easy to be a transplant recipient. These patients need to change their lifestyle and take numerous medications (commonly more than 30 different medications). Hence, all potential transplants patients must undergo psychological testing to identify social and behavioral factors that could interfere with recovery, compliance with medications, and lifestyle changes required after transplantation.

Moreover, needing a heart and being a suitable candidate are not enough. The potential donor heart must be compatible with the recipient’s immune system to decrease the chance of problems with rejection. Finally, this precious resource, the donor organ, must be distributed fairly. The Multi Organ Harvesting Aid Network makes sure that the sickest recipient is given the first preference. As mentioned earlier, this organization makes sure the entire process is fair, structured and transparent.

Results of a Heart Transplant:

In patients with severe heart failure that requires transplantation, the mortality rate within one year is 80%. Five year survival in patients with any form of complex heart disease and heart failure is 50%.

After heart transplant, the one year survival rate averages 90% and five year transplant averages 60%.

Complications of a heart transplant:

The immune system of the body fights against the implanted organ as it sees it as a foreign body. Rejection can be controlled with powerful immunosuppressive medications that greatly reduce the chances of complete organ rejection. Even while there is no active rejection, there is a possibility of acute chronic rejection which causes the growth of tissues in heart vessels. This eventually leads to blockage and finally the organ fails to pump. This is the main factor why heart transplant does not have good long term results.

Immunosuppressive drugs greatly reduce the chances of rejection but also increase the chances of infection in the recipient. The recipient is prone to the most common infections and some may eventually die of developing cancer.

How does a heart transplant patient know if he or she is rejecting the donor organ or developing an infection?

Symptoms

• Weakness,
• Fatigue
• malaise (feeling lousy),
• fever, and
• “flu-like symptoms”, such as chills, headaches, dizziness, diarrhea, nausea and/or vomiting.

In such cases, the recipient has to immediately seek medical attention and perform all required tests so that it can be treated appropriately.

How is rejection of the organ diagnosed and monitored?

The standard for monitoring rejection is the endomyocardial biopsy. This is a simple operation for the experienced cardiologist and can be done as an outpatient procedure. First, a catheter is put into the jugular vein in the neck. From there, the catheter is advanced into the right side of the heart (right ventricle) using an x-ray method called fluoroscopy for guidance. The catheter has a bioptome at its end, a set of two small cups which can be closed to pinch off and remove small samples of heart muscle. The tissue is processed and placed on glass slides to be reviewed under the microscope by a pathologist. Based on the findings, the pathologist can determine whether or not there is rejection.

Immunosuppressive therapy is then adjusted, for example, increased if rejection is present. Investigators have tried to develop less invasive methods to monitor for rejection. There is a new high-tech analysis that can be done in a sample of blood that is very promising and much easier for the patient than the endomyocardial biopsy. This test looks at the expression of specific genes in cells in the blood. The amount of expression of key genes indicates whether or not rejection is occurring. Nevertheless, so far, no method has replaced the endomyocardial biopsy.