Endocarditis - is known since ancient times, the disease is a connective tissue inner lining of the heart caused by infectious or autoimmune agent.Today endocarditis poorly cured and develops into serious complications.Even after the use of the latest methods of treatment, recurrence of endocarditis is approaching 10%.Most complications bring more trouble than the actual disease.Heart defects, which are formed later, incurable and constantly make themselves felt, thereby making it impossible to work and reducing the standard of living.Localization of lesions endocardial different: suffering as a valve unit and parietal sheath.Intrigue endocarditis is the lack of subjective symptoms, and in their late diagnosis of the disease becomes complicate shape.
endocarditis provoked emergence of infectious and noninfectious agents, and depends on what kind of disease.
Infective endocarditis is a bacterial, viral, fungal.The vast majority of bacterial endocarditis a
Non-infectious endocarditis develops most often under the influence of antibodies against its own tissues.Autoimmune antibodies produced in the body as a result of rheumatic fever, as well as autoimmune diseases, caused in most cases the formation of aseptic endocarditis and valvular heart disease later.Sometimes the injury provokes heart endocarditis.
Rheumatism - a disease of the connective tissue of the allergic nature, which occurs after a sore throat caused by streptococcus viridans, and can cause inflammation of the endocardium.Sore Throat in 0.3-3% of cases end with rheumatic fever.Streptococcus produce M protein that causes an autoimmune response of the organism to the connective tissue.The direct participation of streptococcus in inflammation does not accept, the symptoms develop after treatment of angina.
Endocarditis in children deserves special attention.It is congenital or acquired.Congenital endocarditis caused due to infections that during pregnancy the mother was ill.Causes of acquired endocarditis in children correspond to those in adults.
nonspecific signs of endocarditis include fever, chills, fatigue, fever more 38˚S, joint pain, weight loss.Sometimes these symptoms may wear worn out and do not occur in the elderly.Characteristic features can be - warm dry skin, enlarged spleen.
Specific symptoms of infective endocarditis include noise and heart failure, as well as signs of embolism.The nature of the noise depends on the affected valve.The presence of neurological symptoms, speaks of a brain embolism.There may be ischemia of the limbs and organs of the abdominal cavity.Bleeding in the skin produce hemorrhagic rash of petechiae, subungual hemorrhage, Osler nodes (nodules on the palmar side of the fingers), Dzheynveya sores (painful sores on the palms and soles).
a result of infectious endocarditis, heart defects are formed.Aortic stenosis can occur when sprouting vegetation in the area of the valve.It is manifested in the later stages of endocarditis, as well the left ventricle compensates for the failure of its function.The patient complains of shortness of breath and exercise intolerance, on the compressive chest pain.Sometimes, when the load event of loss of consciousness.The skin of such a patient is pale, slow heart rate, blood pressure is lowered.
Aortic insufficiency often is associated with infective endocarditis.The patient complains of palpitations, especially lying on his left side, fatigue, shortness of breath.Later begin to show swelling in the legs, the liver increases, indicating that the formation of the heart failure.Pulse fast.Diastolic pressure is dramatically reduced, sometimes to zero.
Mitral stenosis in infective endocarditis is not formed.Mitral insufficiency is manifested by shortness of breath with exercise, and at rest, hoarseness due to compression of the nerve which is responsible for the voice, the left atrium, cough, hemoptysis, edema, cyanosis of the lips.
defeat of the tricuspid valve is typical for addicts injecting drug injection.Deficiency manifests shortness of breath, fatigue, throbbing neck vessels, a feeling of heaviness in the liver, yellowness of the skin and mucous membranes, cyanosis (cyanosis) limbs.Spinal stenosis is characterized by arrhythmia, cyanosis of extremities, yellow skin.The liver is enlarged, swollen neck veins.
Pathology pulmonary valve appears as a relative failure and is often asymptomatic.
rheumatic endocarditis preceded by streptococcal tonsillitis.Systemic manifestations of rheumatic fever may be accompanied by rheumatic heart disease, and may not be available.This marked heart murmur, expanding the boundaries of the heart, arrhythmia, congestive heart failure.
rheumatic heart diseases are formed in the following sequence: mitral insufficiency, mitral stenosis, aortic regurgitation, aortic stenosis.Tricuspid valve is rarely affected.All life is the progression of valvular, regardless of exacerbation or remission.Appears and progressive heart failure, which can manifest attacks of breathlessness and hemoptysis.
deposits on the damaged valve with time detach and cause embolic complications.This produces ischemia and myocardial spleen lower extremity, intestines, resulting in emergency surgery.
children endocarditis Symptoms: expressed general intoxication in the form of fever, night sweats, fever, body aches, joint pain.Characterized by a rapid transition to a generalized process.The rest is similar to the adult symptoms.
Infective endocarditis is an inflammatory disease of the endocardium infectious nature that affects primarily heart valve, at least - parietal endocarditis prosthetic valve.
Infective endocarditis are diagnosed each thousandth of hospitalized patients.The "modern" infectious endocarditis has a number of features: more and more people suffer from the disease over 50 years and injecting drug users.In view of the frequent use of catheters currently in large vessels, the infectious agent belongs to the group of nosocomial infections.The complication rate is high even with adequate treatment;becoming less infectious endocarditis occurs on the Rheumatic modified valves.
old classification of infective endocarditis divided into acute and subacute.According to this classification, acute septic endocarditis accompanies the process and proceeds rapidly, often striking intact valves.Subacute endocarditis is more protracted as a result of prolonged infection and weakening of the immune system.
Modern classification includes the following criteria:
1) Activity: Active / healing;
2) recurrence: return (repeated within a year after treatment) / persistent;
3) the accuracy of the diagnosis: some / suspect / possible;
5) the affected area: aortic, mitral valve, etc .;
6) special circumstances: the prosthesis endocarditis, pacemaker.
of infectious endocarditis begins with damage to the valve or the wall of the endocardium.Adhere to damaged areas of blood components which provide a substrate for bacteria that circulate in the blood.Then there is their reproduction and formation of the so-called vegetations.Vegetation is a formation consisting of platelets, fibrin, bacteria, white blood cells and endocardial tissue fragments.Their size may vary.Naturally, this prevents the formation of blood flow and prevents the complete closure of the valve.Thus formed defect.The infectious agent is in addition to the vegetation, can directly damage the endocardium, forming ulcers and abscesses.
Big risk of infective endocarditis occurs when the valve replacement, pacemaker installation and catheterization of the heart chambers.In the area of welds and contact with a foreign body endocardial create suitable conditions for the formation of vegetations.
Severe complication is the separation of vegetation and getting it into the bloodstream.This will lead to emboli, the caliber of which depends on the size of the growing season.Thus, there is a large number of ingress of bacteria or fungus to other organs and formation there chronic inflammatory foci.
agents of infectious endocarditis are bacteria, protozoa (eg, rickettsiae), viruses, fungi.
For diagnosis using specific criteria.The diagnosis of infective endocarditis exhibit the presence of two large, one large and three small, or five small features.Large signs: the detection of the pathogen in the blood, the presence of vegetation in the echocardiography, education vice.Small signs: predisposition, fever 38˚S, embolic complications, positive culture, serologic evidence.
endocarditis The main research method is echocardiography.With it rendered the vegetation, the valves, the direction of blood flow.Reverse blood flow, or regurgitation occurs in advanced disease.
special note especially infectious endocarditis in intravenous drug users.Most often, there is a mixed infectious nature, low immunity and frequent HIV infection.
The most common form of infectious endocarditis is bacterial.The most common pathogens are streptococci of this form - up to 80% of crops.Staphylococci make up 25%, including 23% from Staphylococcus aureus.Enterococci are detected up to 18% of cases.Gram-negative aerobes occur in crops of less than 5%.
peculiarity of bacterial endocarditis are the entrance gates, which are the focus of inflammation.Often the disease is accompanied by sepsis, especially characteristic of the acute course.
most dangerous and swift-flowing version of endocarditis - septic.In the old classification was called acute endocarditis.The most common cause of its occurrence are heart surgery, catheterization of the heart chambers, prosthetics.10% of all heart surgery complicated by endocarditis.Period of complications - 14-30 hours.In this case, nosocomial pathogens are strains.In the vast majority of cases are detected in the crop Staphylococcus, Pseudomonas aeruginosa, and fungi.
main attendant phenomenon of septic endocarditis is a pathogen in the blood circulation.It is cyclical, so a negative result of crop does not say about the absence of bacteremia.Take blood for culture need to repeatedly, and best of all before the start of antibiotic therapy, and at least five times.
But the entry of microorganisms in the surgical wound is not enough for the occurrence of endocarditis.An essential factor is the reduction of reactive properties of the organism.
great importance in the development of endocarditis has a local tissue damage.On the damaged area attached platelets and fibrin, and eventually microorganisms.
very difficult for patients with endocarditis caused by Pseudomonas aeruginosa.In these patients, a high percentage of mortality.The destruction of the valve device is very fast and difficult to treat.Endocarditis caused by Escherichia coli, more favorable, more amenable to antibiotic therapy.
Fungal Sepsis occurs when the body's reactivity oppressed and long-term use of antibiotics.Defeats valve apparatus in this type of pathology tougher.The incidence - 2-4% of all cases of endocarditis.
possible emergence of bacterial endocarditis rheumatic modified valves.In this case, endocarditis preceded by bacteremia.Sepsis and rheumatic heart disease often have similar symptoms.
clinical manifestations of bacterial endocarditis is that against the background of severe sepsis with general intoxication progresses heart murmur.The general analysis of blood marked leukocytosis, leukocyte formula shift to the left, the erythrocyte sedimentation rate of 20-25 mm per hour.In the urine appear hyaline and granular casts, protein.When treatment failure in the pathological process involved all organs.Developing renal, respiratory, cardiac failure.
Subacute endocarditis is smoother symptoms and favorable course.Postoperative complications occur gradually.The most common pathogen is Streptococcus, who lives in the mouth and throat.Check pathogen occurs at the valves have changed as a result of rheumatic heart disease, syphilitic lesions, birth defects.
symptomatology is undulating in nature and occurs at 2-3 days after surgery.There the temperature to 39˚S, chills, muscle aches, chest distension, enlargement of the spleen, excessive sweating.This variant proceeds purulent disease without metastasis to other tissues.
Depending on the course of subacute endocarditis, there are several options: first - with prolonged fever and embolic complications that lead to death within a few months, the second - the type of ambulatory flowing without fever.Depending on the leading symptom is isolated anemic, splenomegalic, hepato-splenomegalic, nephritic and other options.
Principles of treatment.In the first place in the therapeutic treatment of infective endocarditis beyond antibiotics.Before you assign a particular antibiotic is necessary to conduct bacteriological examination of blood.But we must remember that 10% of the crop comes up with a negative result.In this case, antibiotic treatment administered empirically.
Gentamicin administered at a dose of 1 mg / kg / every 8 h., With the need to continually monitor the concentration of drug in the blood.Streptomycin - 7.5 mg / kg / every 12 hours. Aminoglycosides carries a certain risk for the liver, kidneys, however the presence of hepatic, renal failure, these drugs should be limited.
Vancomycin - Representative glycopeptides.The dose at normal liver function is 1g every 12 hours / in.Required monitoring of the concentration of drug in the blood.The content should not exceed 20 mg / l.
Teicoplanin administered at a dose of 10 mg / kg every 12 hours. The concentration of drug in the blood for a period of treatment should not be below 20 mg / l.
penicillin antibiotic such as ampicillin and amoxicillin should be administered in / in 2 g every 6 hours, as the period of validity of their very short.With reduced kidney function need to adjust the dose.
We must remember that at the moment a lot of people are allergic to penicillin antibiotics.In such cases, should be given Ceftriaxone 2 g / in p 1 a day.
When endocarditis is progressing rapidly, and wait for culture results do not have time, then resort to the empirical antibiotic therapy.If the patient is in a serious condition, which is typical for sepsis, it should be given flucloxacillin of 8-12g per day for 6 fractional doses of gentamicin and 1 mg / kg per day.
In less severe course of endocarditis is recommended penicillin and gentamicin.In the presence of a prosthetic valve or pacemaker appointed Vancomycin 1g dose every 12 hours and Rifampicin - 300-600 mg every 12 hours inside.
duration of antibiotic therapy should be at least 4 weeks, while the protracted process - 6 weeks.in a day.