Endocarditis: Inflammation of the inner lining of the heart

Endocarditis: Inflammation of the inner lining of the heart

Endocarditis, or inflammation of the inner lining of the heart, often affects children and adolescents and can lead to severe heart valve damage. Since acute endocarditis is potentially life-threatening, the inflammation can also impact life expectancy. What are the symptoms of inflammation of the inner wall of the heart? What are the causes, and how is it treated? You can find out here.

What is endocarditis?

Endocarditis is an inflammation of the connective tissue lining of the heart. It is usually the result of a bacterial infection. The endocardium (endo = inside and card = related to the heart) are the connective tissue structures that partially line the heart’s interior and form the heart valves. Due to the pumping actions of the heart muscle and the resulting blood flow, the freely movable parts of the endocardium remain in constant motion, like the valves of a motor. They are thus exposed to substantial mechanical stress.

Inflammatory processes in the endocardium, known as endocarditis, can lead to severe scarring, adhesions and functional restrictions of the heart valves – with far-reaching effects on the performance of the heart muscle and, thus, on the circulatory function. Acute endocarditis is potentially life-threatening – and fatal in over 15 per cent of cases.


Causes and forms of endocarditis

Endocarditis usually occurs either as an incorrect immune system reaction after a streptococcal infection (rheumatic endocarditis) or in inflammatory processes caused by microbes (infectious endocarditis). The mitral valve, i.e. the valve between the atrium and ventricle in the left heart, is particularly frequently affected.

A distinction is made between two forms of endocarditis:

  • rheumatic endocarditis
  • infectious endocarditis

Causes of rheumatic endocarditis

Rheumatic endocarditis often affects the endocardium, the entire heart muscle (myocardium), and the heart’s outer layer (pericardium). The trigger is a previous infection with a specific type of bacterial pathogen. A malfunction in the body’s defences can lead to an excessive immune system reaction, whereby the body’s tissue is attacked rather than the disease-causing pathogens – in this case, the endocardium, especially the heart valves. This reaction is one of the autoimmune diseases.

Other diseases can trigger such non-infectious (abacterial) endocarditis in rarer cases. These can lead to inflammation of the connective tissue throughout the body – and thus to inflammation of the connective tissue heart valves. These include, for example, chronic polyarthritisBechterew’s disease and lupus erythematosus.


Infectious endocarditis: bacteria as a trigger

In contrast, in infective endocarditis, inflammation of the valve tissue is caused directly by bacteria that colonize and multiply in situ (bacterial endocarditis). Fungi can also cause endocarditis.

Symptoms of endocarditis

Rheumatic endocarditis is more common in children and adolescents than in adults. Bacterial endocarditis can develop very suddenly (acute form) and then quickly lead to high fever, weakness and joint problems, sometimes skin changes (minor bleeding) and shortness of breath.

In the more common insidious (subacute) form, slowly developing non-specific symptoms are more prominent, for example

  • fatigue
  • exhaustion
  • derating
  • slight increase in temperature
  • night sweats or
  • Decrease in red blood pigment

It is not uncommon for the possibility of severe heart disease to be overlooked at first and only considered when a (new) heart murmur occurs during listening.

Endocarditis: how is it diagnosed?

If it persists for a long time, symptoms of cardiac insufficiency can occur. If endocarditis is detected too late, inflammation can repeatedly develop on the previously damaged heart valve and irreparably damage the heart valves (chronic course). Therefore, early diagnosis of endocarditis is crucial.

Even if the doctor cannot view the inflammatory process on the heart valves directly, some tools make it easier to diagnose endocarditis. The medical history is therefore essential for the doctor, particularly previous tonsillitis or joint inflammation and other complaints. During the physical examination, he pays particular attention to bleeding in the skin and mucous membranes and when listening to heart murmurs.

Cardiac ultrasound can show more muscular inflammation, deposits and changes in the heart valves. An ECG shows whether the inflammation myocarditis ) also affects the heart muscle. If endocarditis is suspected, blood cultures are created several times to identify the underlying germ as far as possible. This is the best way to find a suitable antibiotic or antifungal agent. 


complications and course

The most severe complication of acute bacterial endocarditis is the life-threatening general infection of the whole organism sepsis ), which is fueled again and again by the inflammatory “smouldering fire” in the endocardium and can lead to death. In addition, individual particles of the inflammatory deposits can detach from the heart valves, travel with the bloodstream to the brain, clog important vessels there and thus cause a stroke. 

If the acute phase is survived, irreparable heart valve damage can develop – especially in the case of chronic, recurring endocarditis – which in the long term weakens the heart muscle, impairs cardiovascular function and can also damage the lungs.

An advanced defect in the mitral and aortic valves, most commonly affected by endocarditis, can eventually lead to cardiac insufficiency, and there is also an increased risk of a particular cardiac arrhythmiaatrial fibrillation. This irregular, chaotic rhythm of the atrium promotes the formation of blood clots, which in turn can travel to the brain and trigger strokes.

Long-term consequences and chance of survival in endocarditis

The long-term effects of endocarditis essentially depend on early diagnosis and effective treatment – especially since an endocarditis-damaged heart valve is particularly susceptible to repeated colonization by pathogens due to the increased mechanical stress.

If the therapy for rheumatic endocarditis starts in good time, both acute damage to the heart valves and chronic consequential damage caused by recurring inflammatory processes can be largely avoided. In the acute form of bacterial endocarditis, deaths must be expected at 30 to 40 per cent, even in the age of modern medicine.

Treat endocarditis

In treating endocarditis, antibiotics are used to combat the germs, and drugs are used to fight the inflammatory reactions. The underlying diseases and sequelae are also treated. In addition, an operation is often necessary. This is what the treatment of endocarditis looks like:

  • The most crucial pillar of therapy is the administration of antibiotics – this is also started on suspicion before the pathogen has been detected. The duration of the treatment is individually adjusted (usually four to six weeks) – especially in the case of rheumatic endocarditis; the antibiotic treatment must be continued over a more extended period to prevent a relapse. In addition, aspirin and cortisone are given for rheumatic endocarditis.
  • In the case of severe acute forms and chronic, irreparable consequential damage to the valve apparatus, heart surgery often has to be carried out, and the inflamed or chronically deformed heart valve replaced with a heart valve prosthesis. This effectively removes the focus of inflammation and improves the heart’s performance. However, prostheses have two disadvantages: their limited lifespan and they require lifelong blood thinning medication.
  • Sometimes, the surgeon can repair the defective valve by tightening or stretching it so that no prosthesis is necessary.
  • heart transplant can also be considered the last measure in the event of severe cardiac insufficiency after damage to the heart valve.
  • In addition, the consequences of chronic heart valve damage, such as cardiac arrhythmia or cardiac insufficiency, are also treated individually.
  • Suppose endocarditis occurs as an accompanying reaction in the context of other severe diseases of the organism, such as chronic polyarthritis. In that case, the treatment must aim to eliminate the underlying problem, an immune disease.

Although it is often not possible to prevent an initial disease, targeted and consistent treatment of the endocarditis that has occurred can at least control or curb the progression of inflammation and valve damage.


Higher risk for those already affected

Once you have had endocarditis, you are, in principle, more at risk of developing it again. Therefore, those affected – as well as patients with an artificial heart valve and a severe congenital heart defect – should be lifelong before any planned diagnostic or therapeutic medical intervention in which germs can get into the bloodstream (e.g. tooth removal, gastrointestinal pharynx) receive a preventive – usually one-off dose of antibiotics (endocarditis prophylaxis).

However, in the case of certain valve defects, several interventions do not lead to an increased risk of endocarditis, which is why the formerly stringent guidelines were relaxed somewhat in 2007.

To ensure that the disease does not worsen, regular follow-up examinations by the doctor are recommended, during which drug therapy can be adjusted if necessary. In addition, those affected should have a heart pass issued, which they should present for all (planned) treatments and not forget when they are on vacation.

Important information for endocarditis sufferers

Patients with endocarditis should note the following:

  • always have your heart pass with you and present it
  • good, regular dental hygiene with a soft toothbrush
  • In the case of bacterial infections, have a doctor prescribe antibiotic therapy for a sufficiently long period


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