Endocarditis means inflammation of the inner layer of the heart.

The heart walls

made up of three layers, the epicardium being the outermost layer, then the
myocardium, then the endocardium, which is the layer that gets inflamed. It turns
out that most cases of endocarditis are due to a microbial infection of the
endocardium usually involving the endocardium lining the cardiac valves. Why the
valves? Well, it turns out that the valves have tiny blood vessels that nourish them,
even though theyre flopping around in blood all day long. That means that an
infection can potentially result from a damaged valve since that would allow
microbes to escape the tiny blood vessels and invade the valve tissue, or on the flip
side microbes in the blood might enter the tiny vessels within the valve. Either way,
a microbe has to first get into the bloodstream, and that might happen if a person
has an obvious open wound or an abscess, a dental or surgical procedure, or
injection, with an infected needle or in with an infected needle or infected substance
usually while using illicit drugs. Most often the valves on the left side are affected,
the mitral valve and the aortic valve, sometimes due to predisposing conditions like
mitral valve prolapse and bicuspid aortic valves, but it really depends on the
circumstances. Risk factors for either valve include having prosthetic valves, having
a congenital cardiac defect involving the valves, having damage to the valves from
rheumatic heart disease, and finally intavenous drug use can put valves at riskwhich typically the tricuspid valve. Now the first step that happens in endocarditis is
something causes the endothelial lining of the valve gets damaged, and there are a
number of ways that can happen like previous inflammation/injury. That damage
exposes the underlying collagen and tissue factor, which causes platelets and fibrin
to adhere, which forms this tiny thrombosis or blood clot. This is called Nonbacterial
Thrombotic Endocarditis or NBTE, and its nonbacterial because it happens even
before the bacteria shows up. Now if you add in bacteriemia, or bacteria in the
blood, youve got yourself a recipe for infective endocarditis. Every day, there are
opportunities for microbes to get into the bloodstream whether its through brushing
your teeth and having them slip into the gums, or having them slip in through your
gut or lungs, whatever the case they regularly make their way into the body. Its not
usually not a problem because its a small amount and can easily be killed by our
immune system, but occasionally they float around in the blood for long enough to
find an NBTE which serves as a perfect location for them to attach to and set up an
infection called a vegetation. To attach to it a lot of bacterial species use proteins on
their surface called adhesins, that let them stick to the valve as we stick to one
another. They also create an extracellular matrix around themselves-called biofilm
which allows them to literally stick together and from a large clump of bacteria that
can behave like a colony. Usually these guys stick to area of lower pressures, since
its easier to adhere. So, lets take mitral valve regurgitation, where blood flows
backward from the higher pressure left ventricle to the lower pressure left atrium.
So in this case, vegetations will tend to form on the lower pressure atrial surface.
Not only that, though, theyll form on the edge of the opening, and this is because
of the venturi effect. The venturi effect describes how fluid pressure decreases as it
flows through a narrowed opening, while its velocity increases. So as blood forces
its way through the opening, pressure is lower near the edges. If the person had
aortic regurgitation, meaning bloods going from the higher pressure aorta to the
lower pressure ventricle, then veghetations would tend to be located on the lower

pressure ventricular surface of the valve. Inefective endocarditis used to be

classified into groups like acute and subacute based on how quickly the infection
developed, but nowadays the key is to identity that microbial cause of infection and
to treat it as effectively as possible. Viridans streptococci is the most common
cause. Its virulence is low, its found in the mouth, and they usually attack valves
that have had some previous damage, usually resulting small vegetations which
dont destroy the valve. Staphylococcus aureus, on the other hand, is a highly
virulent bacteria that can be found on the skin, and this guy can infect both
damaged and healthy valves-often the tricuspid valve. S aureus causes large
vegetations that can destroy the valve, and is the bacteria most commonly
contacted from intavenous drug use. Next we have staphylococcus epidermidis,
which is a bacteria that loves foreign prosthetic, material, likke prosthetic heart
valves. One way that the bacteria gets into the body is at the time of heart valve
surgery and it literally sticks around on the valve. Another common point of entry
into the body though is through an infected intravenous catheter. Both of these
scenarios usually happen in a hospital, so this would be considered a nosocomial
infection. Two other bacterial species are enterococcus faecalis and streptococcus
bovius which are both normally found in the gut flora. When somebody has severe
coloretal disease, like colorectal cancer or ulcerative colitis, these gut bactyeria can
migrate across the gut lining and into the bloodstream, which becomes a setup for
potential endocarditis. An even more unusual bacteria is coxiella burnetii which
patients typically contarct after exposure to infected animals like cows, sheep, and
goats. The bacteria initially causes a disease called q fever, but months or
sometimes years after the initial q fever, they can develop endocarditis, but usually
this is in high-risk people, like those that are immunocompromised, pregnant
women, and those with pre-existing heart valve defect, making it tricky to diagnose
unless theres a reason to suspect it. Finally, a group of organisms that are less
commonly associated with endocarditis are the HACEK organisms. These guys are
group of gram-negative bacteria that are also part of the normal flora of the mouth
and throat. Each letter of HACEK stands for a different genus-Haemophilus,
Aggregatibacter, Cardiobacterium, Eikenella, and Kingella. Now people with
inefective endocarditis almost always have a fever, as well as a new heart murmur,
that results from turbulent blood flow past a damaged heart valve. Sometimes
those vegetations can detach from the valve, and little clupms of pathogens can
float through thye bloodstream called septic emboli. These guys can lodge under
the fingernails, causing splinter hemorrhages, or in the palms and soles of the feet,
causing small painless, flat, and erythematous lesions, called janeway lesions.
Separately there might be an immune reaction with antigen-antibody complexes
that form and deposit in different parts of the body. In the fingers and toes, these
complexes can lead to painful lesions called oslers nodes, in the eye these deposits
can lead to roth spot, and in the kidney they can lead to glomerulonephritis.
Diagnosing the cause of infective endocarditis, typically involves getting positive
blood culture, which is literally growing bacteria from a blood sample.
Echocardiography can also be used to visualize the heart and look for vegetations
or more subtle clues like the way a valve is moving. Depending on the organism
that caused the infection, a prolonged course of antibiotics will likely be used to try
and wipe out the infection but surgery might be needed for severe cases, especially

when valve dysfunction causes heart failure. Its also important to prevent
endocarditis especially among high risk groups like for example those with
prosthetic heart valves and a history endocarditis. Before dental procedures,
sometimes these people are recommended antibiotics, since remember that some
of those microbes that cause endocarditis live in the mouth. Finally, theres libmansacks endocarditis, which is not infection-related. This ones usually associated with
systemic lupus erythematosus, which is an autoimmune disease involving antigenantibody complees, and in this case they settle in the endocardium and cause
inflmmation. These areas of inflammation can happen anywhere on the valve
surface or chordae tendineae, but typically happen on the mitral valve, leading to
mitral valve regurgitation. In this case, inflammation can also happen on the atrial
endocardium or ventricular endocardium. Alright, so to recap, endocarditis or
inflammation of the endocardium typically develops from bacterial infection-usually
in this case theres first some damage or injury to the heart valves, which leads to
thrombi which serves as a place for bacteria to adhere to and cause infalammation.
Sometimes, though, it can be nonbacterial, one example being libman-sacks
endocarditis, which is associated with lupus-an autoimmune disease.