Infective endocarditis: diagnosis and management

Despite advances in antimicrobial therapy, diagnostic imaging and cardiac surgery, infective endocarditis (IE) remains challenging clinically and is associated with high morbidity and mortality. Diagnosis relies on several factors: initial clinical suspicion, microbiological data and echocardiographic findings. The use of an integrated diagnostic schema, such as the modified Duke criteria, is useful. Transthoracic or transesophageal echocardiography should be performed promptly for all suspected IE cases. Although the choice of investigation might be influenced by availability, the approach to imaging should be tailored to the individual's clinical situation. Promptly administered intravenous antimicrobial therapy is essential, while the use of antiplatelet or antithrombin therapy to prevent embolic complications is not supported by clinical data. Deciding whether to undertake cardiac surgery for the treatment of IE can be extremely difficult. The principal indications are the development of heart failure from acute, severe aortic or mitral regurgitation, or perivalvular extension of infection. The timing of surgery following central nervous system embolization is problematic because of the risk of hemorrhagic transformation. Prophylactic surgery to prevent embolization is currently advocated only for the management of large, mobile vegetations, when undertaken at centers performing high volumes of heart valve surgery. In this review, we describe diagnostic approaches for IE, particularly echocardiography, and provide recommendations for treatment, paying particular attention to surgery in the acute setting.