|Year : 2014 | Volume
| Issue : 1 | Page : 29-32
Is there a role for tissue doppler imaging in infective endocarditis?
Andrea Sonaglioni1, Elisabetta Rigamonti2, Graziana Trotta1, Michele Lombardo1
1 Department of Cardiology, Ospedale San Giuseppe-Multimedica, Via San Vittore 12, 20123 Milan, Italy
2 Department of Cardiac Rehabilitation, Ospedale San Giuseppe-Multimedica, Via San Vittore 12, 20123 Milan, Italy
|Date of Web Publication||12-May-2014|
Via Ludovico Cavaleri 5, 20147 Milan
Source of Support: None, Conflict of Interest: None
An 87-year-old woman was admitted to our Cardiology Department with symptoms and signs of acute congestive heart failure and fever. She had a long history of hypertension and chronic atrial fibrillation. Transthoracic echocardiography showed a large (>10 mm) and mobile mitral valve vegetation, prolapsing into the left ventricular inflow tract, with severe mitral regurgitation due to a perforation in the posterior leaflet, in a mitral valve with fibro-calcific degeneration. Mitral regurgitation was hemodynamically significant and a moderate-to-severe pulmonary hypertension was observed.Tissue Doppler Imaging recorded at the level of the vegetation detected its incoherent motion and measured the peak antegrade velocity, which was found to be almost four times higher than that sampled at the lateral mitral annulus. Blood cultures were negative for both aerobic and anaerobic microbes. During hospitalization, the patient developed a sudden onset of left-side hemiplegia. Diffusion-weighted magnetic resonance imaging demonstrated multiple hyperintense lesions involving both hemispheres, suggestive of a cardioembolism. Diagnosis of fungal endocarditis was made and a treatment with fluconazole was started. Successive echocardiograms showed a decrease in the size and mobility of the mitral vegetation, and an increase in its echo intensity. However, in view of the systemic conditions severely affected, the patient was treated conservatively and died 3 months later. In our patient echocardiography played a key role for a better definition of the clinical course. In this context, Tissue Doppler Imaging might provide an adjunctive parameter for the prediction of embolic risk from endocardial vegetations: the peak antegrade velocity recorded at the level of the vegetation. However, before being adopted in clinical setting, this parameter should be validated by adequately powered prospective studies.
Keywords: Cardioembolism, fungal endocarditis, Tissue Doppler Imaging
|How to cite this article:|
Sonaglioni A, Rigamonti E, Trotta G, Lombardo M. Is there a role for tissue doppler imaging in infective endocarditis?. J Cardiovasc Echography 2014;24:29-32
|How to cite this URL:|
Sonaglioni A, Rigamonti E, Trotta G, Lombardo M. Is there a role for tissue doppler imaging in infective endocarditis?. J Cardiovasc Echography [serial online] 2014 [cited 2023 Feb 2];24:29-32. Available from: https://www.jcecho.org/text.asp?2014/24/1/29/132284
| Clinical course|| |
On August 15 th , 2013, an 87-year-old woman was admitted to our Cardiology Department with symptoms and signs of acute congestive heart failure and fever. She had a long history of hypertension and chronic atrial fibrillation.
Electrocardiogram showed an atrial fibrillation with normal intraventricular conduction and a controlled ventricular rate (heart rate 68 bpm).
Chest X-rays revealed cardiomegaly with bilateral hilar congestion.
Blood tests documented neutrophilic leukocytosis (white blood cells 26,000/ml) and high levels of N-terminal prohormone of brain natriuretic peptide (NT-proBNP; 11,000 pg/ml), inflammatory markers (eritrosedimentation rate 40 mm and C-reactive protein 17.6 mg/dl) and procalcitonin (0.21 ng/ml).
Transthoracic echocardiography detected a single large vegetation, >10 mm in length, with the same consistency as the myocardial echoes, with a small area of attachment to the atrial side of the lateral mitral valve annulus and with a rapid oscillating motion, prolapsing into the left ventricular inflow tract, and completely different to the surrounding tissue [Figure 1].
|Figure 1: Transthoracic echocardiogram in the acute phase. Four apical chamber section. Single large vegetation with echogenicity similar to that of the myocardium and with a small area of attachment to the atrial side of the lateral mitral valve annulus. This mass showed a rapid oscillatory movement, prolapsing into the inflow tract of the left ventricle, clearly distinct from the normal pattern of valve movement. The result was a massive mitral regurgitation due to a perforation in the posterior leaflet, in a native mitral valve with fibrocalcific degeneration|
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It was associated with a severe mitral regurgitation due to a perforation in the posterior leaflet. A moderate-to-severe (3-4+/4+) tricuspid regurgitation, a significant caval venous congestion, and a moderate-to-severe pulmonary hypertension, with a systolic pulmonary artery pressure (PAPs) value of 60 mmHg, were diagnosed too. The left ventricle was hypertrophic (interventricular septum thickness 13 mm), had reduced endocavitary dimensions (end diastolic volume 30 ml/m 2 ) and a slightly depressed global contractile function (ejection fraction, calculated using Simpson's method monoplane, was 48%).
Tissue Doppler Imaging (TDI) was performed simultaneously; placing the pulsed wave (PW) sample volume at the level of the mass, it detected its incoherent motion, a rapid irregular movement unrelated to the cardiac cycle or cardiac structures as a result of free oscillation, with a prolapse in the left ventricular inflow tract. Furthermore, PW-TDI precisely characterized the vegetation mobility, by measuring a peak antegrade velocity of 38.5 cm/s [Figure 2], almost four times higher than the one obtained placing the sample volume at the level of the lateral mitral valve annulus.
|Figure 2: Pattern of pulsed wave-Tissue Doppler Imaging (PW-TDI) recorded at the level of the endocardial vegetation in the acute phase. Four apical chamber section. The vegetation exhibited a pattern of incoherent motion: an oscillatory movement, rapid and independent from the surrounding tissue, not related to the cardiac cycle. It was measured a peak antegrade velocity of 38.5 cm/s, about four times higher than that obtained at the lateral mitral annulus|
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Three subsequent blood cultures were found to be negative for both aerobic and anaerobic microbes.
The patient was initially treated with intravenous (IV) diuretics (furosemide 60 mg/day), then underwent antibiotic therapy with IV vancomycin (1,500 mg/day) and ceftriaxone (2 g/day), and suspected of having a fungal endocarditis, antifungal therapy with IV fluconazole (100 mg/day).
In the following days of hospitalization, the patient developed a sudden onset of left hemiplegia.
A cerebral computed tomography (CT) scan showed no areas of altered signal intensity, but magnetic resonance imaging (MRI) demonstrated multiple hyperintense lesions involving both hemispheres, suggestive of a cardioembolism [Figure 3].
|Figure 3: Brain magnetic resonance imaging (MRI). Axial diffusion-weighted imaging (DWI) MRI sequences. In the context of a chronic vascular disease, multiple and bilateral hyperintense lesions, suggestive of a cardioembolism|
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Ongoing echocardiograms revealed a gradual decrease in the size of the mitral vegetation and an increase in its echo intensity [Figure 4]; a concomitant reduction in its mobility was assessed by PW-TDI [Figure 5].
|Figure 4: Transthoracic echocardiogram performed after 2 weeks of intravenous antifungal therapy with fluconazole, in addition to antibiotic therapy with vancomycin and ceftriaxone. Four apical chamber section. Reduction in the size and increased echogenicity of endocardial vegetation, partially calcified, pedunculated, and no longer prolapsing into the inflow tract of the left ventricle|
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|Figure 5: Pattern of PW-TDI obtained at the level of the mass after 2 weeks of intravenous antifungal therapy with fluconazole, in addition to antibiotic therapy with vancomycin and ceftriaxone. Significant reduction in motility of the vegetation (peak antegrade velocity of 6 cm/s)|
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However, a significant hemodynamically mitral regurgitation persisted.
Taking into account the serious clinical condition of the patient and the recent episode of embolic stroke, we agreed with cardiac surgeons to opt for medical therapy alone.
In the following weeks, the patient's conditions worsened and she died 3 months after the diagnosis.
| Discussion|| |
Neurologic events occur in 20-40% of patients with infective endocarditis (IE), mainly through the embolic occlusion of cerebral arteries arising from endocardial vegetation. 
Echocardiography plays a key role in predicting embolic events. 
Several factors are associated with increased risk of embolism:
- Vegetation size: patients with vegetation length >10 mm are at higher risk of embolism,  and this risk is even higher in patients with very large (>15 mm) and mobile vegetations; 
- Vegetation mobility: from fixed to prolapsing; 
- Vegetation consistency: calcified lesions do not have embolic potentiality; those with a consistency equal or inferior to that of myocardial echoes are associated with increased risk of embolic complications; 
- Vegetation extent: involvement of a single valve leaflet (particularly the location on the mitral valve) or multiple valve leaflets, the extension to extravalvular structures; 
- The increasing or decreasing size of the vegetation under antibiotic therapy; 
- Particular microorganisms (Staphylococci  , Streptococcus bovis , Candida spp.);
- Previous embolism; 
- Biological markers. 
In the present case, clinical features of the patient (old and weakened), negative blood cultures, the vegetation's large size, and the response to antifungal therapy with IV fluconazole, suggested a diagnosis of fungal endocarditis.
The risk of embolization in cases of fungal endocarditis is very high; in fact, many authors recommend early surgical intervention in this situation to avoid neurological complications. 
PW-TDI is an echocardiographic technique, introduced by Isaaz et al.,  and Mc-Dicken et al.,  in the early 1990s, with a high temporal resolution.
It permits to obtain high-quality Doppler signals and a rapid quantitation of velocity, acceleration, and displacement of different ventricular wall segments.
Moreover, PW-TDI is able to discriminate the fine movements of intracardiac masses, and in particular, to identify endocardial vegetations by their characteristic pattern of incoherent motion. 
This pattern is due to the free oscillation of an anomalous structure, with velocity and direction of movement independent from and completely different than the surrounding tissue and without any correlation to the cardiac cycle.
Although PW-TDI suffers from some limitations (the need for manually performed mapping; a limited spatial resolution; identification of anomalous structures may be difficult due to the superimposed color), in our opinion these critical cautions should not decrease its potential utility in clinical practice.
In our case, placing the PW-TDI sample volume at the level of the mitral valve vegetation, made it possible to precisely measure its motility, by means of the peak antegrade velocity: This was found to be about four times higher than that sampled at the lateral mitral annulus. Despite the absence of standardized criteria of increased velocity in the clinical practice, we hypothesize that PW-TDI might provide an adjunctive echocardiographic parameter for prediction of embolic risk in IE: the peak antegrade velocity recorded at the level of the vegetation.
However, before being adopted in clinical setting, this parameter should be validated by adequately powered prospective studies.
| References|| |
|1.||Garcia-Cabrera E, Fernandez-Hidalgo N, Almirante B, Ivanova-Georgieva R, Noureddine M, Plata A, et al. Group for the Study of Cardiovascular Infections of the Andalusian Society of Infectious Diseases, Spanish Network for Research in Infectious Diseases. Neurological complications of infective endocarditis: risk factors, outcome, and impact of cardiac surgery: a multicenter observational study. Circulation 2013;127:2272-84. |
|2.||Thuny F, Di Salvo G, Belliard O, Avierinos JF, Pergola V, Rosenberg V, et al. Risk of embolism and death in infective endocarditis: Prognostic value of echocardiography: a prospective multicenter study. Circulation 2005;112:69-75. |
|3.||Leitman M, Dreznik Y, Tyomkin V, Fuchs T, Krakover R, Vered Z. Vegetation size in patients with infective endocarditis. Eur Heart J Cardiovasc Imaging 2012;13:330-8. |
|4.||Okonta KE, Adamu YB. What size of vegetation is an indication for surgery in endocarditis? Interact Cardiovasc Thorac Surg 2012;15:1052-6. |
|5.||Di Salvo G, Habib G, Pergola V, Avierinos JF, Philip E, Casalta JP, et al. Echocardiography predicts embolic events in infective endocarditis. J Am Coll Cardiol 2001;37:1069-76. |
|6.||Bayer AS, Bolger AF, Taubert KA, Wilson W, Steckelberg J, Karchmer AW, et al. Diagnosis and management of infective endocarditis and its complications. Circulation 1998;98:2936-48. |
|7.||Sanfilippo AJ, Picard MH, Newell JB, Rosas E, Davidoff R, Thomas JD, et al. Echocardiographic assessment of patients with infectious endocarditis: prediction of risk for complications. J Am Coll Cardiol 1991;18:1191-9. |
|8.||Vilacosta I, Graupner C, San Roman JA, Sarriá C, Ronderos R, Fernández C, et al. Risk of embolization after institution of antibiotic therapy for infective endocarditis. J Am Coll Cardiol 2002;39:1489-95. |
|9.||Hubert S, Thuny F, Resseguier N, Giorgi R, Tribouilloy C, Le Dolley Y, et al. Prediction of symptomatic embolism in infective endocarditis: construction and validation of a risk calculator in a multicenter cohort. J Am Coll Cardiol 2013;62:1384-92. |
|10.||Pergola V, Di Salvo G, Habib G, Avierinos JF, Philip E, Vailloud JM, et al. Comparison of clinical and echocardiographic characteristics of Streptococcus bovis endocarditis with that caused by other pathogens. Am J Cardiol 2001;88:871-5. |
|11.||Durante Mangoni E, Adinolfi LE, Tripodi MF, Andreana A, Gambardella M, Ragone E, et al. Risk factors for 'major' embolic events in hospitalized patients with infective endocarditis. Am Heart J 2003;146:311-6. |
|12.||Tacke D, Koehler P, Cornely OA. Fungal endocarditis. Curr Opin Infect Dis 2013;26:501-7. |
|13.||Isaaz K, Thompson A, Ethevenot G, Cloez JL, Brembilla B, Pernot C. Doppler echocardiographic measurement of low velocity motion of the left ventricular posterior wall. Am J Cardiol 1989;64:66-75. |
|14.||McDicken WN, Sutherland GR, Moran CM, Gordon LN. Colour Doppler velocity imaging of the myocardium. Ultrasound Med Biol 1992;18:651-4. |
|15.||Bartel T, Muller S, Nesser HJ, Mohlenkamp S, Bruch C, Erbel R. Usefulness of motion patterns identified by tissue Doppler echocardiography for diagnosing various cardiac masses, particularly valvular vegetations. Am J Cardiol 1999;8:1428-33. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]