Infectious Endocarditis (IE)- this is an infective, more often bacterial, polypose-ulcer damage to the valve apparatus of the heart and the closed endocardium, accompanied by the formation of vegetation and the development of valve deficiency due to the destruction of its sash, characterized by systemic damage to vessels and internal organs, as well as thromboembolic complications.

Epidemiology.The incidence of infectious endocarditis is an average of 30-40 cases per 100,000 population. Men sick in 2 - 3 times more often of women, among the diseases prevail their working age (20-50 years old). Distinguish primary EE., developing on the background of intact valves (in 30-40% of cases), and secondary IE, Developing against the background of previously altered valves and sublocked structures (congenital and acquired valve defects of the heart, prosthetic valves, mitral valve prolapse, post-infarction aneurysms, artificial vascular shunts, etc.).

In recent years, there has been a steady increase in the incidence of IE, which is associated with the widespread dissemination of invasive methods of examination and surgical treatment, the growth of drug addiction and the number of persons with immunodeficiency states.

The peculiarities of the "modern" infectious endocarditis include:

The increase in the frequency of the disease in the elderly and old age (more than 20% of cases).

Increasing the frequency of primary (on intact valves) Form IE.

The emergence of new forms of the disease - IE drug addicts, IE prosthetized valve, IE nodogenic (nosocomial) due to hemodialysis, infection of intravenous catheters, hormone therapy and chemotherapy.

Failure in infectious endocarditis, despite the emergence of new generations of antibiotics, remains at a high level - 24-30%, and in older people - more than 40%.

EtiologyIE is distinguished by a wide range of pathogens:

1. Samoa frequent cause Diseases are streptococci (up to 60 - 80% of all cases), among which the most common pathogen is considered green Streptococcus (at 30 - 40%). Factors contributing to the activation of streptococcus are purulent diseases and surgical interventions in the oral cavity and nasopharynx. Streptococcal endocardits are distinguished by a subacute flow.

In recent years, the etiological role has increased enterococcus Especially with EE in patients who have undergone weighting operations on the abdominal cavity, urological or gynecological operations. Enterococcal endocardits are distinguished by malignant current and resistance to most antibiotics.

2. In second place in frequency among etiological factors IE is located golden Staphylococcus (10 -27%), the invasion of which occurs against the background of surgical and cardiac surgical manipulations, at an injection drug addiction, against the background of osteomyelitis, abscesses of various localization. For staphylococcal endocardits, the acute flow and frequent damage to intact valves are characterized.

3. The most difficult to occur EE caused by gram-negative microflora (intestinal, sinic sticks, protea, microorganisms of the member group), developing more often in injection drug addicts and alcoholism persons.

4. Against the background of immunodeficiency states of various genesis, IE is developing mixed etiology, including pathogenic mushrooms, rickettsia, chlamydia, viruses and other infectious agents.

Thus, the most frequent entrance gate infection These are: Operational interventions and invasive procedures in the oral cavity, urinary sphere related to the opening of abscesses to various localization, heart surgery, including valve prosthetics, aorto-coronary shunting, long-term catheter penette in Vienna, frequent intravenous infusion, especially injecting addiction, Chronic hemodialysis.

Due to the frequent start of antibacterial therapy before studying the blood of patients with IE on sterility, it is not always possible to identify the causative agent of the disease. In 20 - 40% of patients, the etiology of the disease remains unknown, which makes it difficult to appoint adequate antibacterial therapy.

Pathogenesis.In the development of IE, the following pathogenetic mechanisms can be distinguished:

1. Transient bacteremiawhich can be observed with any surgical interventions on the abdominal organs, the urogenital system, on the heart, vessels, nasopharynx organs, during the extraction of the tooth. The source of bacteriamia can be purulent infections of various localization, invasive studies of internal organs (bladder catheterization, bronchoscopy, colonoscopy, etc.), as well as non-compliance with sterility in injections from drug addicts. Thus, short-term bacteremia is a frequent phenomenon that does not necessarily lead to the development of IE. For the occurrence of the disease, additional conditions are needed.

2. Endothelium damageit develops as a result of impact on endockard of high-speed and turbulent blood flows, due to metabolic violations of endocardium in elderly and senile people. In the presence of the original valve pathology, the risk of transformation of bacteremia in IE reaches 90% (according to M.A. Gurevich et al., 2001). Many invasive diagnostic and operational interventions are accompanied by damage to the endothelium and, it means a high risk of developing IE.

3 . In the zone of damaged endothelium, most often on the surface of the sash valves of the heart occurs platelet adhesion,their aggregation and formation of thrombocyte cloth thrombus with fibrin deposition. In the conditions of Bacteriamia, microorganisms from the blood stream are deposited on the microtrombach and form colonies. On top view, new portions of platelets and fibrin are layered on them, which cover microorganisms from the action of phagocytes and other anti-infectious protection factors. As a result, large polypo-shaped clusters of platelets, microorganisms and fibrin, which are called on the surface of the endothelium vegetations. Microorganisms in vegetation have favorable conditions for breeding and vital activity, which leads to the progression of the infectious process.

4. Weakening of the organism resistanceas a result of various external and internal factors, it is a prerequisite for the development of an infectious hearth in the heart under conditions of Bacteriamia.

5. As a result infectious destruction The flaps of the valve sash and the subcase structures occurs perforation of the sash, the separation of tendon threads, which leads to acute development of insufficiency of the affected valve.

6. Against the background of a pronounced local infectious destructive process in the body, general immunopathological reactions are naturally developing (inhibition of the T-system of lymphocytes and activation of the B-system, the formation of circulating immune complexes (CEC), the synthesis of autoantibodies to its own damaged tissues, etc.), which leads to immune process generalization.As a result of immunocomplex reactions, systemic vasculites are developed, glomerulonephritis, myocarditis, polyarthritis, etc.

7. For EE characteristic thromboembolic complications:infected thromboembols, which are particles of vegetation or destroyed valve, migrate through the arterial channel of a large or small circle of blood circulation - depending on the lesion of the endocarda of the left or right heart chambers, and form microabscesses of organs (brain, kidneys, spleen, lungs, etc.).

8. The progression of IE naturally leads to development cardiac and renal failure.

Patanatomy.The left heads of the heart are more affected - the aortic and mitral valves, with the drug addicts - mostly a three-rolled valve. Vegetations are revealed on endocardium, consisting of platelets, fibrin and colonies of microorganisms, perforation or separation of flaps, tearing tendon chord. Vegetations are more likely to occur during valve insufficiency than in the stenosis of the valve opening, and are located preferably on the atrial side of the mitral valve or on the ventricular side - aortic. Characterized by the micrones of vessels, abscesses of internal organs.

Classification IE

Clinico-morphological:

primary IE,

secondary IE.

By etiology:streptococcal, enterococcal, staphylococcal, protein, fungal, etc.

With the flow:

acute, durable less than 2 months,

subacute, durability for more than 2 months,

chronic recurrent flow.

Special forms of EE:

Hospital (nosocomial) IE:

IE prosthetized valve,

IE in persons with a pacemaker (ex),

IE in persons on program hemodialysis.

Ie at Narkomanov

IE in people of elderly and senile age

Clinical picture:

The modern clinical course of IE is distinguished by the predominance

subacute or atypical forms of the disease with an erased clinical symptom. Sometimes the disease is diagnosed only at the stage of acute destruction of the heart valves or the development of systemic immunopathological processes in the form of vasculitis, glomerulonephritis, etc.

When describing the IE clinic, domestic scientists (A.A. DEMIN, 2005) traditionally distinguish 3 pathogenetic stages of disease, characterized by clinical, laboratory and morphological indicators and treatment principles:

Infectious-toxic.

Immunovipal.

Dystrophic.

Complaints.The first symptoms usually appear in 1-2 2 weeks after the episode of Bacteremia. It - fever and intoxication. With a subacute, endocardite disease begins with a subfebrile temperature, which is accompanied by a common weakness, cognition, sweating, rapid fatigue, decreased appetite, heartbeat. During this period, the correct diagnosis is usually not installed. The symptoms arising as viral infection, myocarditis, tuberculosis intoxication, etc.

A few weeks later, a hectic or permanent fever is installed with a body temperature lifting up to 38 - 39 o and pronounced chills, night sweating, weight loss at 10 - 15 kg, headaches, arthralgia and Malgia. Cardiac complaints appear and progress: shortness of breath during exercise, pain in the heart, resistant tachycardia. Despite the severity of clinical symptoms, the diagnosis of IE in the absence of signs of the formed heart failure can not be installed yet. At this time, the decisive moment can be the detection of vegetation on the valves using echocardiography. In the development of the damage of the damaged valve, signs of levels or right-hand deficiency quickly appear, which is accompanied by characteristic physical and instrumental data, making the diagnosis of EE obvious. In the formation of heart defects against the background of perforation of valve valve and destruction of valve vegetations, thromboembolic complications often arise with the development of ischemic stroke, a silence infarct, kidney (at left-sided IE) and lungs (at right-sided IE), which is accompanied by characteristic complaints. For fungal Ia, thromboembolism in the artery of the limbs with the development of mycotic aneurysm or foot necrosis

In a later immunocamipal stage, complaints appear, testifying to the development of glomerulonephritis, hemorrhagic vasculitis, myocarditis, arthritis, etc.

Lookingrevealed pallor of skin With a grayish-yellowish tint (color "coffee with milk"), which is associated with the anemia characteristic of IE, involvement in the process of the liver and hemolysis of erythrocytes. The weight loss is rapidly developing. The characteristic changes of the end phalange of the fingers are detected in the form of "Drum sticks" and nails by type "Hour glasses", Emerging sometimes after 2 - 3 months of illness. On the skin of patients (on the front surface chest, on the limbs) may be observed petechial hemorrhagic rash (painless, not pale with pressing). Sometimes Petechia is localized at the transitional fold of the conjunctivities of the lower eyelid spots Lukina or on the mucous membrane of the oral cavity. In the center of small hemorrhages in the conjunctival and mucous membranes there is a characteristic zone of pale. Similar to appearance rota spots Defined on the retina of the eye in the eye study. In soles and palms of the patient may be observed painless red janeway spots diameter 1 - 4 mm. The appearance of linear hemorrhages under the nails of the fingers is possible. Characteristic nodes of Osler - painful reddish formations with a pea size, located in the skin and subcutaneous tissue on the palms and soles associated with the development of thrombovasculitis. Reveal positive symptoms Tie (Gekhta) I. sample RUME-LEDE-Konchalovskywhich indicate an increased fragility of small vessels due to vasculitis. When conducting samples, the cuff is superimposed on the shoulder to measure blood pressure and it creates a constant pressure equal to 100 mm Hg, for 5 minutes. With increased permeability of vessels or thrombocytopathy (decrease in platelet function), more than 10 patechs on an area of \u200b\u200ba limited diameter of 5 cm appear below.

In the study lymph nodes Lymphadenopathy is often detected.

When developing heart failure, detected exterior signs stagnant phenomena for a large or small circulation of blood circulation

(position orthop, cyanosis, swelling of legs, swelling of the cervical veins, etc.).

With thromboembolic complications, characteristic external signs are also identified: paralysis, paresa, signs of TEL, etc.

Cardiac manifestations of IE:

Under the acute course of the IE and the rapid destruction of the affected valve, an acute left left ventricular or right-hand deficiency with characteristic objective features is developing. The lesion of the aortic valve is observed in 55 - 65% of cases, the mitral valve - at 15-40%, the simultaneous lesion of the aortic and mitral valves - in 13%, the three-risk valve - in 1-5%, but among drug addicts, this localization is detected in 50% of patients. .

Percussion and auxual signs of valve defects during primary IE, the character of the pulse and hell mainly correspond to physical manifestations of rheumatic heart defects.

It is a complex diagnosis of IE, which has connected to already existing innate or rheumatic heart defects. With differential diagnosis, along with anamnesis and characteristic non-recorded signs of IE, the emergence of new or change in the earlier cardiac noise due to the formation of new heart defects is taken into account.

Change abdominal organsmanifested in increasing liver and splenomegaly (in 50% of patients) associated with generalized infection and frequent thromboembolic infarction of the spleen.

Complications of IE.:

Abscess fibrous rings valve and its destruction.

Diffuse myocarditis.

Heart failure, including acute during valve destruction.

Thromboembolism (in 35-65%) patients.

Miocardial abscess, septic infarction of lungs, spleen, brain.

Glomerulonephritis, leading to chronic renal failure.

Diagnostics:

1. A general blood testdetects leukocytosis with leukoformula shift to the left, an increase in ESP to 50-70 mm / hour, normal anemia due to oppression bone marrow. Establishing ESP is usually preserved 3-6 months.

2. Biochemical blood testrelaxes expressed disproteinemia due to the reduction of albumin and an increase in the content of α 2 and γ-globulins, the content of fibrinogen, sermukoid, is increased, a C-jet protein appears, positive sedimentary samples - forms, sulea, thymol. In 50% of patients, a rheumatoid factor is detected.

3. Sowing blood for sterilitymay appear to confirm the diagnosis of IE and the choice of adequate antibacterial therapy. To obtain reliable results, the blood fence must be carried out before the start of antibacterial therapy or after the short-term cancellation of antibiotics in compliance with all the ranges and antiseptic rules by puncture or artery. In the area of \u200b\u200bthe vessel puncture, double-handed skin treatment with antiseptic, palpate vein follows in sterile gloves, from veins take 5-10 ml venous blood In 2 bottles with nutritional environments and immediately send them to the laboratory.

With acute IE, blood is taken three times with an interval of 30 minutes at the height of the fever, with a subacute of IE, a three-year blood pressure is carried out within 24 hours. If after 2-3 days the growth of the flora is not recommended to produce sowing 2-3 times. With a positive result, the number of bacteria ranges from 1 to 200 per 1 ml of blood. Their sensitivity to antibiotics is determined.

4. Electrocardiographyit may identify signs of focal or diffuse myocarditis, thromboembolism in coronary arteries is accompanied by extracts of myocardial infarction, thromboembolism in the pulmonary artery (TEL) will be manifested by the ecg-signs of acute overload of the right ventricle.

5. Echocardiographyin many cases, it allows you to identify direct signs of IE - vegetation on the valves, if their dimensions exceed 2-3 mm, evaluate their shape, magnitude and mobility. There are also signs of breaking tendon chord, perforations of valve sesters, forming valve heart defects.

Cardiologist

Higher education:

Cardiologist

Kabardino-Balkarian State University. HM Berbekova, Faculty of Medicine (KBSU)

Education Level - Specialist

Additional education:

"Cardiology"

GOU "Institute of Improvement of Doctors" Ministry of Health and Social Development of Chuvashia

In the list cardiology diseases Includes infectious endocarditis. It is dangerous possible complications (myocarditis, kidney damage, lungs, liver, central nervous system). In the event of the development of this pathology, patients are mandatory to be hospitalized.

Development of endocarditis in children and adults

The endocardium is called the inner layer of the heart, which lifts the cavity of the atrial and ventricles. It is also formed by heart valves that take part in unidirectional blood movement. Infectious endocarditis is called inflammatory disease of the inner shell of infectious origin. This is not transmitted from one person to another type of heart pathology. The pathogens may be a variety of microorganisms (bacteria, viruses).

The level of morbidity in the world ranges from 3 to 10 cases per 100,000 people. The progression of endocarditis leads to the destruction of valves and impaired their functioning. The consequence of all this is the development of their insufficiency. Most often in the process involve aortic and mitral valves. The first is located between the left ventricle and the aorta, and the second - between the left hearts.

The main purpose of the valve apparatus is an obstacle to the reverse blood cast. This eliminates the overload of ventricles and atrial. In recent years, the number of patients with infectious myocarditis has increased. Causes - immunodeficiency, frequent heart surgery and the use of invasive treatment methods.

The disease can occur in a recurrent form. With this pathology, the percentage of fatal outcomes is high. Almost every third patient dies without due medical care. In 2015, this cardiac pathology was detected mainly in the young population aged 20 to 50 years. Often the disease develops from drug addicts and persons with reduced immunity. Less often inflammation of endocardia is observed in childhood.

What happens endocarditis

The classification of infectious endocarditis is known not to everyone. It is divided according to the following signs:

• the reason for the occurrence;
• clinical morphological form;
• the nature of the flow;
• localization.

Depending on the main cause of inflammation, primary and secondary endocarditis are isolated. They have a fundamental difference between themselves. In the primary form of endocarditis, inflammation develops against the background of sharp infectious states (sepsis, septicemia, septicopemia). In this case, the valves were originally not changed. Secondary endocarditis is a complication of another pathology. The disease can flow in acute, subacute and protracted form.

In the first case, the symptoms are worried about a person for no more than 2 months. The most common cause is sepsis. It takes very hard. Subacute endocarditis lasts more than 2 months. If complaints and signs of the lesion of the heart shell persist for a long time, then such an endocarditis is called a protracted one. Inflammation can only be limited to valve flaps or go beyond their limits. Highlight 3 clinical forms of the disease:

• infectious-allergic;
• infectious toxic;
• dystrophic.

The toxic type of endocarditis has the following signs:

• leads to the formation of microbial growths;
• leads to transient bacteremia;
• accompanied by the defeat of other organs.

In the case of the progression of the pathological process, a dystrophic form of inflammation is developing. With it, irreversible changes are observed. The infectious-allergic form of endocarditis is characterized in that it leads to jade, hepatitis and other complications. There is another classification that is based on the activity of the inflammatory process. It allows you to judge the condition of the patient. According to it, the aligned and active endocardits distinguish.

Etiological factors

The etiology of the infectious endocarditis knows only the doctor. The following causes of the lesion of the heart sheath and the valves of the microbes are distinguished:

• congenital heartfall;
• impairment of hemodynamics (blood circulation);
• acquired vices;
• secondary immunodeficiency against the background of HIV infection, drug addiction, alcoholism, smoking, diabetes;
• operational interventions;
• septic conditions;
• bactemey;
• valve prolapse;
• valve prosthetics;
• rheumatism;
• atherosclerosis;
• implementation of the pacemaker.

Secondary infectious endocarditis develops mainly against the background of congenital heart defects and rheumatism. The impairment of hemodynamics leads to damage to the valve apparatus and the affection of the endocardium. This disease becomes the cause of heart failure and vasculitis. The pathogenesis of infectious endocarditis is based on adhesion (sticking) of microbes to endocardium and valves.

It is most often happening from drug addicts, alcoholics and older people. Risk factors include the use of drugs overwhelming immunity. The most frequent pathogens of endocarditis are staphylococci, streptococci, enterococci and fungi. Total known more than 120 types of microbes that can cause this heart pathology.

From this largely depends on the forecast for health. The highest rates of mortality are observed when infected with epidermal and gold streptococci. The share of fungal endocarditis accounts for up to 7% of all cases of illness. The highest activity of the inflammatory process is observed against the background of an infection caused by anaerobic microflora.

The new stage of the development of medicine entailed the appearance of diseases caused by the residence of a person in a hospital. It is often a nosocomial endocarditis. It develops within 48 hours after a person's arrival in the hospital. The endocarditis not related to hospitalization may arise at home. This is facilitated by hemodialysis, intravenous administration medicines, care for a sick person. Separately allocated repeated endocarditis, which develops after some time after the primary inflammation.

Clinical manifestations of endocarditis

With infectious endocarditis, symptoms are determined by the following factors:

• age of man;
• illness of the disease;
• species of pathogen;
• concomitant pathology;
• the cause of inflammation.

The sharp shape of the endocarditis caused by pathogenic stamps of staphylococcus flows. In this disease, the following symptoms are observed:

• fever;
• chills;
• sweat rings;
• the pallor of the skin and visible mucousse;
• gray skin shade;
• small hemorrhages on the skin;
• chest pain;
• lack of appetite;
• weight loss;
• weakness.

The manifestations of intoxication are the most permanent diagnostic sign. It is due to the presence of microbes and their toxins. The temperature in patients may be subfebrile or hectic. Frequent manifestation Endocarditis is shortness of breath. It is due to heart failure. Small blood vessels of patients become fragile.

It is manifested by multiple hemorrhages (petechias). They appear in the region of the clavicle, century, nails, mucous membranes. Specific symptom of endocarditis are company spots. They are hemorrhages in mesh shell eyes. Similar changes are detected at an ophthalmic examination.

The subacute infectious endocarditis is often manifested by the symptom of drum sticks and hourly glasses. Patients thicken the phalange of the fingers. Often on the skin appear nodules of the Osler. This is a sign of septic endocarditis. A distinctive feature of the disease is the development of complications in the early period.

Complications and consequences of endocarditis

In presentations on the infectious endocarditis of famous doctors, possible complications of this disease are always indicated. This pathology may lead to the following consequences:

• damage to the kidney in the type of glomerulonephritis;
• hepatitis;
• embolia of brain vessels;
• thromboembolia pulmonary artery;
• slezen's heart attack;
• septic shock;
• respiratory distress syndrome;
• heart pathology;
• stroke;
• paresis;
• paralymp;
• brain abscess;
• aneurysm;
• vasculitis;
• thrombosis;
• thrombophlebitis.

With endocardium, the infection spreads through the body, leading to a violation of the function of all vital organs. The kidneys are very often amazed. The process involves predominantly the glomerular apparatus, which is responsible for filtering blood plasma. Glomerulonephritis develops. It is manifested by a decrease in diurea, high pressure and edema syndrome.

In 2015, many people died from renal pathology. Complications of infectious endocarditis include blood thickening and the formation of thrombus. The latter can cause inflammation of blood vessels and their blockage. With pulmonary artery thromboembolism, the likelihood of a lung infarction is high. This is a dangerous state due to the acute lack of oxygen.

The infarction is manifested by pain in the chest, shortness of breath, difficult to breathe. In the case of the tomb of the thrombus and the blockage of cerebral vessels they can develop ischemic stroke. It is manifested by a disorder of consciousness, a violation of speech and a motor function, weakness in the legs and arms, dizziness. Neurological complications include meningitis, strip paresis, brain abscess. If the therapy of the infectious endocarditis is not carried out, the development of secondary arterial hypertension is possible.

If the doctor has a presentation on endocarditis, he knows that against the background of this disease, the heart is suffering. In the absence of proper treatment, there is a risk of developing defects (deficiency of mitral and aortic valves), myocarditis and inflammation of the near-carrying bag. To the most dangerous consequences Endocarditis includes septic shock and acute respiratory failure. In case of late treatment of respiratory distress syndrome, mortality reaches 70%.

How to reveal endocarditis

Diagnosis and treatment are conducted by a doctor. To reveal endocarditis in a patient, you need to hold a number of studies:

• clinical analysis of blood and urine;
• biochemical study;
• tonometry;
• physical research (percussion and auscultation);
• study of blood coagulation;
• immunological study;
• sowing blood;
• review X-ray;
• echocardiography;
• study of heart noise;
• spiral computed tomography;

Consultation of several specialists (cardiologist, pulmonic, therapist, ophthalmologist) may be required. In case of suspected infectious endocarditis, the diagnosis necessarily includes heart ultrasound. This is the main and most informative method for assessing the condition of the heart chambers and valves. Echography is simple and percussive. In the latter case, the sensor is introduced through the esophagus.

During the ultrasound, the following changes are detected:

• vegetation (accumulation of microbes together with blood clots);
• small purulent cavities in the field of valve;
• valve failure.

To establish the pathogen, a polymerase chain reaction can be carried out. The diagnosis of infectious endocarditis includes a survey, inspection, blood pressure and pulse, listen to lungs and hearts. In the process of auscultation, signs of valve deficiency are often detected. Pathological noise and weak heart tones are listened. During the damage to the liver and kidneys, biochemical blood biochemical changes change dramatically.

Treatment of patients with endocarditis

After the diagnosis is raised, proceed to treatment. The main documents that take into account the doctor, assigning medicines, is the history of the disease and an outpatient map. When the endocarditis is detected, hospitalization is shown. Therapy is combined. Next treatment is carried out:

• symptomatic;
• etiotropic;
• pathogenetic;
• radical (surgical).

There are various recommendations, but always with a given disease, systemic antimicrobial drugs are prescribed. Most often it is antibiotics. Pre-determined the type of bacteria. When revealing streptococci, antibiotic therapy is carried out within 4 weeks. Breaks do not. In the case of staphylococci selection, treatment of infectious endocarditis can be delayed for a month and a half.

The longest therapy requires inflammation due to anaerobic microflora. It is recommended to use modern antibiotics Wide spectrum. They need to be administered intravenously or intramuscularly. The most effective penicillins (benzylpenicillin, phenoxymethylpenicilline, ampicillin, amoxiclav). Penicillins are often combined with aminoglycosides.

Antibacterial treatment is terminated in normalization of temperature, negative results of microbiological research and normalization of blood and urine indicators. Recommendations for treatment are known to each doctor. According to the indications, anti-staphylococcal globulin is introduced. With infectious endocarditis, symptomatic therapy is carried out.

The following drug groups can be used:

• diuretics;
• anesthetics (NSAIDs and analgesics);
• aCE inhibitors;
• nitrates;
• heart glycosides.

Treatment recommendations include the reception of antiagregants and anticoagulants. This reduces the likelihood of thrombosis and vascular embolism. Any good lecture or presentation on the topic of endocarditis states that to eliminate the symptoms of intoxication requires massive infusion therapy.

Strong fever is an indication for the appointment of antipyretic drugs. With the damage to the heart, medications are often prescribed, reduced the load on the organ. Treatment recommendations include the use of systemic glucocorticoids (prednisone). With infectious endocarditance, treatment implies plasmapheresis.

Radical methods of treatment and forecast

A competent presentation or lecture on endocardite states that in severe cases of one drug treatment is not always enough. Operation is required when developing complications. Surgical treatment is planned, emergency and deferred. In the first case, the help is in the first 24 hours. The urgent surgery is carried out within a few days. Often, radical treatment is delayed.

Antibiotic therapy is performed. The urgent surgery is shown in heart failure, long, repeating fever and non-efficiency of drugs. Often, treatment recommendations include surgical intervention in order to prevent embolism. This is possible with large vegetation and high risk of thrombom education. Very often there is an intervention for the replacement of valves for artificial.

Endocarditis is one of the most dangerous cardiovascular diseases, so the forecast is not always favorable. In the case of acute inflammation without treatment, a person dies in 1-1.5 months from complications. In the elderly, the forecast is worse. In 10-15% of cases, acute endocarditis goes into chronic with periodic exacerbations.

How to prevent endocarditis development

Specific prevention of infectious endocarditis is absent. The transfer of infection from the patient to healthy does not occur, so contact with other people does not play roles in the development of this pathology. Any presentation on endocarditis includes prevention. To avoid damage to endocardium and valves, you need to adhere to the following recommendations:

• in time to treat infectious diseases (pyelonephritis, pneumonia, caries, sinusitis, tonsillitis);
• eliminate supercooling;
• move more;
• abandon alcohol and cigarettes;
• do sport;
• treat heart disease;
• eliminate all sorts of operations;
• eat right;
• warn overcooling;
• eliminate contact with patients with influenza or angina;
• raise immunity;
• refuse narcotic drugs.

Very often the heart is amazed against the background of sepsis. To avoid it, it is necessary to conduct a sanation of foci of infection and with the slightest complaints to contact the doctor. With the risk of infection, a short course of antibiotic therapy may be carried out in order to prevent. Thus, endocarditis is a dangerous heart pathology. When the first symptoms appear, you need to contact a cardiologist or therapist.

Rheumatism is an infectious-allergic disease, which is based on inflammation and disorganization of connective tissue. The main cause of rheumatism is considered to be beta-hemolytic streptococcus Group A. When first contact with this microorganism, the patient usually suffers from tonsillitis or pharyngitis ( in childhood). Without qualified medication treatment, the initial disease passes within 1 - 2 weeks. However, then the most dangerous phase occurs.

The human immune system begins to produce antibodies against the causative agent. In some cases, this reaction becomes excessively strong ( hypeergic immune response). In such patients, antibodies begin to attack connecting tissue cells ( mainly in the cardiovascular system). Such inflammation is called rheumatism.

With rheumatic endocarditis, the following heart structures are most often affected:

• mitral valve;
• aortic valve;
• three-profile valve ( usually in combination with other localizations);
• tendon chords;
• parietal ( parietal) endocard;
• deep layers of myocardium.

Thus, with rheumatic endocardium, the inflammation is somewhat different, rather than with the most common, infectious form. This explains the differences in the course of the disease and its manifestation. Similar heart damage may occur in patients with a systemic red lupus.

Injuries

Endocarditis due to injury develops after operations or invasive diagnostic procedures on the heart and is often a consequence of medical errors. Usually it flows in the form of small clusters of thrombotic masses in the field of heart valves. Inflammatory phenomena are not expressed. The problem can be only gradual valve deformation ( usually the narrowing of the fibrous ring). Forecast with timely detection of traumatic endocarditis is always favorable.

Allergic reaction

Allergic endocarditis develops rarely. Its reason is the individual sensitivity of the body to certain chemical compounds (allergenam) And their getting into the bloodstream. Often, the role of allergens are medicines. Patients and do not suspect the presence of the intolerance of any drug. In such cases, endocarditis develops during the course of the treatment of another disease. An allergic form of endocarditis usually proceeds easily and does not have serious consequences. In the future, the patient only advises to avoid repeated contacts with the allergen.

Intoxication

Endocarditis can develop with some types of intoxication. Sometimes the symptoms of this disease are observed with an increase in uric acid levels ( uremia). Such an action can also have some poices or chemicals in the blood. While characteristic of this type of endocarditis is the accumulation of thrombotic masses along the edge of the left ventricular valves. Inflammatory phenomena are quite weak. In this regard, many authors do not even recommend similar states to the endockardites category.

Infection

Bacterial infection is the most common cause of endocarditis all over the world. Viruses are practically not able to affect this heart layer, and the fungal infection is quite rare. The bacteria fall on the clips and chords in the period of bacteremia. At the same time, the causative agents of the disease circulate in the blood. Usually, the primary infectious hearth is other organs and tissues, and the microbes are recorded on endocardium due to ineffective or late treatment. However, there are cases when endocarditis is the only manifestation of the infectious process.

The most frequent pathogens of the bacterial endocarditis are:

• Green Streptococcus (Streptococcus Viridans.) - Approximately 35 - 40% of cases. It is the most frequent causative agent of infectious endocarditis.
• Enterococcus (Enterococcus) - 10 - 15%. It dwells normally in the intestine of a person, but under certain conditions it can be pathogenic ( pause).
• Golden Staphylococcus (Staphylococcus aureus.) - 15 - 20%. It can dwell on the skin or in the nasal cavity of healthy people. Causes severe infectious endocarditis with a serious damage to the valves.
• Streptococcus Pneumoniae. - fifteen%. This microorganism is the causative agent of pneumonia, sinusit or meningitis in children. In the absence of qualified treatment, the endocardium is possible.
• Other streptococci and staphylococci - 15 - 20%. These pathogens usually cause endocarditis with a favorable outlook without serious damage to the valves.
• Bacteria from Hacek Group (Haemophylus, Actinobacillus Actinimycetemcomitans, Cardiobacterium Hominis, Eikenella Corrodens, Kingella Kingae) - 3 - 7%. This group of microorganisms were combined due to their high tropism ( affinity) It is to the endocardium of the heart. Their overall feature are difficulties in diagnosis, because all the bacteria of the Hacek group with difficulty are cultivated on the nutrient media.
• Gram-negative bacteria – 5 – 14% (Shigella, Salmonella, Legionella, Pseudomonas). These bacteria rarely affect endocardia. Usually, in addition to symptoms from the heart, there are violations of the functions of other organs and systems.
• Fungal infections - fifteen%. Fungal infections are also rarely affected by endocard. The problem in such patients is the need for long-term treatment with antifungal agents. Due to the danger of complications, doctors often resort to surgical treatment.
• Other pathogens. In principle, endocarditis can cause almost all known pathogenic bacteria ( chlamydia, brubellla, rickettsia, etc.). Approximately 10 to 25% of cases, it is not possible to highlight the causative agent, although all the symptoms and diagnostic tests speak in favor of the infectious endocarditis.
• Combination of several infectious agents (mixed form). It rarely registers and leads, as a rule, to the severe protracted flow of the disease.

Such a variety of causative agents of infectious endocarditis creates serious difficulties for the diagnosis and treatment of patients. In addition, each microorganism has some individual characteristics, which explains a large number of different symptoms and the variants of the disease.

An important feature of bacterial endocardits is the formation of so-called vegetations on valve flaps. Most often they arise in the left hearts. Vegetations are small accumulations of microorganisms attached to the sash. Usually, a small thrombus is formed at the first stage in the place of damage to the endocardium. Subsequently, it is precisely the first infection pathns that are attached. As they reproduce and enhance the inflammatory process of vegetation, it may increase. If they have a flat form and firmly attached to the sash, they are called immobile. Moving vegetations on the structure resemble polyps on the leg. They seem to hang on the flap of the valve and move depending on the blood current. Such vegetations are the most dangerous, as the separation of this education leads to its injection into the bloodstream and acute thrombosis. The separation of large rolling vegetations is quite frequent cause of serious complications and even death with infectious endocarditis. The severity of the consequences depends on what level the vessel thrombosis occurs.

Separately, it should be considered fibroplastic eosinophilic endocarditis Lefball. The reasons for its development are unknown. With a given disease, it is amazed predominantly trimming pericard, which distinguishes it from other disease options. It is assumed that in the development of endocarditis Lefball play a certain role of complex allergic reactions.

Types of endocarditis

There are many different classifications of endocarditis, each of which reflects the features of the course of the disease in a certain patient. Such a separation was made to facilitate the diagnostic process and systematize a large number of symptoms.

Infectious endocardits can be divided into two main groups:

• Primary infectious endocarditis. The primary is a form of a disease in which bacteria circulating in the blood was detained on the sashs of a healthy valve ( any of the valves) and caused inflammation. This form is rare enough, because healthy endocardium is little susceptible to the causative agents of the disease.
• Secondary infectious endocarditis. Secondary is called endocarditis, in which the infection falls on already damaged heart valves. Such a form of illness is found much more often. The fact is that the narrowing of the valves or their improper work disturb the normal blood flow. Curvy, blood stagnation in certain heart chambers or an increase in internal pressure. All this contributes to microscopic damage to the endocardium, which easily penetrate the bacteria from the blood. Defects predisposing to secondary infection of the heart valves are a rheumatic process, an open arterial duct, a heart partition defect, as well as other congenital or acquired heart defects.

According to the clinical course of the disease, infectious endocarditis can be divided into three forms:

• acute;
• subacute;
• chronic ( protracted).

Acute infectious endocarditis

The most often acute form of endocarditis occurs during staphylococcal sepsis, when microorganisms from this group are circulated in the blood. On the flaps of the valves quickly appear ulcerations and vegetation. Inflammation leads to the release of pathological protein - fibrin. It closes defects and ulcerations, but thickens valve sash, which prevents their normal operation. The condition of patients with this form of endocarditis is heavy. Throughout the disease, high risk of severe complications ( valve Perforation, Vegetation Outside and Thrombosis). Recovery occurs after 1 - 2 months. As a rule, after the elimination of the inflammatory focus of the flap of the valves remain deformed, which explains the residual phenomena after the disease.

Subighteous infectious endocarditis

Subighteous endocarditis lasts more than 2 months ( usually up to 1 - 1.5 years). The ulcer process is less pronounced in this case, and the damage of the valves is not so fast. In rare cases, the disease can occur without explicit damage to the valve apparatus. Inflammation is limited to chords and an entry endocardium. Symptoms in such patients are less pronounced, and the general condition is usually better.

Chronic ( protracted) Infectious endocarditis

This form of endocarditis appears against the background of serious disorders in the structure or operation of the valve apparatus ( secondary endocarditis). The primary defect is present in 85% of cases and contributes to the formation of a chronic focus of infection. This prevents effective treatment And explains the protracted course of the disease. In general, the protracted endocarditis is observed in almost 40% of cases.

The following patient groups are predisposed to the chronic course of the disease:

• Newborn and breastfeeding. The prevalence of chronic endocarditis in children is due to congenital heart valves defects. In these cases, infection and its development on endocardium is usually a matter of time.
• People who use drugs injecting. This category of people has a high probability of toxic damage to the endocardium and the enhancing infection. In addition, in the course of treatment it is possible to re-enhancing microbes. Often, such patients have mixed infections.
• People who have undergone operations on the heart. Diagnostic or therapeutic manipulations in the heart cavity always represent the risk of endocardium trauma. In the future, this creates favorable conditions for the formation of an infectious focus.

In chronic infectious endocardius, periods of remissions and relapses are usually observed. Remissions are improved patient's condition and the disappearance of sharp symptoms. During this period, patients are mainly observed signs of damage to valves, but the infectious focus in the heart is not liquidated. The relapse is called a sharp deterioration in the patient's condition associated with the activation of infection and the development of the acute inflammatory process. This flow is also observed with rheumatic endocarp.

In some countries, in addition to the sharp, subacute and chronic form of endocarditis, there is another abortive measure of the flow. It is characterized by rapid and persistent recovery ( without recurrence). Such an outcome is most favorable, since the valve apparatus of the heart does not have time to suffer due to inflammation. The abutient flow is observed in infectious and toxic endocardits, when the disease was diagnosed at an early stage, and timely treatment was started.

Rheumatic endocarditis has a somewhat different classification. It is not based on the duration of the disease ( because it is always a protracted), and on the nature of changes in cardiac valves. They allow you to estimate the intensity of the inflammatory process and assign the right treatment.

Rheumatic endocarditis is divided into four types:

• Diffuse endocarditis. In this case, there is a change in the structure of the connective tissue over the entire surface of the valve. His sash thicken, which makes it difficult to normal heart. On the surface you can detect small granuloma ( usually appear on the side of the left ventricle on the sashs of a mitral or aortic valve). It is characterized by simultaneous damage to the connective tissue in several places, including chord and cloth endocardium. Timely treatment of such an endocarditis at the step of swelling of the connective tissue helps to avoid irreversible changes. If the granulomas have already appeared, high risk of the battle or shortening valve flaps. Such changes are called rheumatic heart disease.
• Acute warthy endocarditis. This form of the disease is characterized by the detachment of the surface layer of the endocardium. At the place of the defeat there is a deposition of thrombotic masses and fibrin, which leads to the emergence of specific formations, so-called warts. They have the kind of small light brown or gray tubercles. In some cases, there is a sharp increase in these formations with the formation of entire conglomerates on the valve sash. In contrast to vegetations in infectious endocarditance, these formations do not contain pathogenic microorganisms. However, in the case of circulation of microbes in the blood, infection of such warts can occur with the development of secondary infectious endocarditis and the deterioration of the patient's overall state. If inflammation is able to stop on early stagesThe formation on valve sash does not increase. At the same time, there is practically no risk of tomb tomb and a serious impairment of the heart.
• Returnable warthy endocarditis. This type is characterized by changes similar to those with acute warts endockar. The difference consists in the course of the disease. Education on sash appears periodically during the exacerbation of rheumatism. The resistant imposition of fibrin is observed when calcium salts are turned on. Such formations are clearly visible when conducting ECCG ( echocarlyography) or radiography that helps confirm the diagnosis.
• Fibroplastic endocarditis.This form is the final stage of the three previous options for the flow of rheumatic endocarditis. It is characterized by pronounced changes of valve flaps ( their shortening, deformation, splicing). These changes are irreversible and require surgical treatment.

With fibroplastic eosinophilic endocardium Leffler, the disease is classified by flow stages. For each stage, their changes in the heart cavity and the corresponding symptoms are characteristic.

With the endockarization of Lefefler distinguish the following steps:

• Acute necrotic) Stage. The inflammatory process affects endocardia of both ventricles and ( less frequent) Atriality. Not only the surface layer in contact with blood, but also deep layers of myocardium is affected. In the inflamed tissue, a large amount of eosinophils are found ( view of leukocyte). The long-term stage is 5 - 8 weeks.
• Thrombotic stage.At this stage, inflammatory foci in the endocardium begin to be covered with thrombotic masses. Because of this wall, the heart chambers are thickened and their volume decreases. There is a gradual flaw of the endocardium, in which the thick tissue fibers appears in its thicker. The subject to myocardia is thickened due to hypertrophy ( increase in volume) Muscular cells. The main problem at this stage is a pronounced decrease in the volume of ventricles.
• Fibrosis stage. When the connecting tissue in the endocardium was formed, the wall loses its elastic properties. There is an irreversible decrease in the volume of the heart, the weakening of its abbreviations and the damage to tendon chord, which is reflected in the work of the valves. At the same time the picture of chronic heart failure is coming out.

Endocarditis symptoms

Given the variety of endocarditis forms, its clinical manifestations and symptoms can vary in very wide limits. Some of them will be characteristic of any of the options for the disease. These are symptoms that talk about heart disorders and characterize heart failure. In addition, there are a number of manifestations of the disease, which are characteristic only for one form or another ( infectious, rheumatic, etc.). Knowing these symptoms sometimes helps to suspect the correct diagnosis in the first phases of the disease.

Symptoms and signs of heart failure when various forms Endocarditis

Symptom or manifestation of the disease	Description of the symptom	The mechanism of appearance of symptom
Dyspnea	Initially, shortness of breath appears in severe physical exertion. It is characterized in the inability to restore the normal respiratory rhythm. The patient can even start torn, as there is no stable air inflow into the lungs. Dyspnea lasts 1 - 2 minutes and stops after stopping the load. In the later stages, shortness of breath may occur and spontaneously, at rest.	Dyspnea with endocarditis can be due to several pathological mechanisms at once. With an active inflammatory process, the volume of cardiac cameras decreases somewhat. Accordingly, the heart cannot pump the same blood volume as before. There is a stagnation of blood in a small circulation circle ( in the lung vessels). Another reason for stagnation can be the battle of valve flaps or its narrowing. It does not allow blood to pass from one heart chamber to another in sufficient quantity, which also suffers from the pump function. Blood stagnation in the lungs violates gas exchange and the body lacks oxygen. The reflexively violates the rhythm of breathing and shortness of breath occurs.
Heart pain	Heart pain pain is relatively rare for endocarditis symptom. They may occur in late stages of the disease during exercise or during stressful situations.	Most often, the pain is due to a violation of blood flow to the heart muscle. This is explained by the spasm or blockage of coronary vessels that feed myocardium. With endocarditance, these vessels may be clogged by fragments of vegetation on the valves. Moreover, inflammatory process In the area of \u200b\u200bthe aortic valve can contribute to the narrowing of the lumen coronary arterieswho originate near this place.
Tachycardia (heartbeat)	The rapid heartbeat is characteristic practically for any forms of endocarditis. A distinctive feature It is that it is not associated with exercise and usually does not depend on body temperature, as it happens with other diseases.	Tachycardia with infectious endocardius can be explained by hitting microbial toxins and increasing body temperature ( in the early stages of the disease). In the later stages, the cardiac frequency increases reflex. So the body tries to compensate for cardiac insufficiency.
Fingers in the form of "drum sticks" (drum fingers, hippocratic fingers)	This symptom may appear in the later stages of the disease ( more often with rheumatic heart defects). Fingers become narrower, and the last phalanx, on the contrary, expands. This symptom is not characteristic only for endocarditis. It meets with other heart disease, lungs and gastrointestinal tract (less frequent).	Thickening occurs due to the growth of the connective tissue between the nail plate and the bone. The unambiguous mechanism of this process has not yet been established. Nevertheless, the connection of this symptom with chronic tissue hypoxia is clearly traced ( lack of oxygen).
Nails in the shape of watch windows	Nails expand and take more rounded shape. central part nail plate Raised, because of which the nail becomes like a dome. It is clearly noticeable if you ask the patient to compare the final phalanxies big fingers back side ( symptom of Shamrota).	This symptom usually develops in parallel with drum fingers. The mechanism of their occurrence is similar. The process affects all fingers.
Pallor skin	The skin's pallor can appear with any form of endocarditis and at any stage. As a rule, it depends on the stage of heart failure. With a protracted course of the disease or with severe damage to the valves, not only the pallor may be observed, but even the formation ( akrcyanosis) The tip of the nose and fingers.	The skin's pallor is explained by the fact that the heart does not supply with tissues enough oxygen. The volume of pumped blood may fall due to the weakening of heart abbreviations, narrowing valves or thickening the walls of the heart ( the amount of heart chamber itself decreases).
Fast fatiguability	Fast fatigue, like shortness of breath, appears in the first stages of the disease only during exercise. Over time, the patient can start tired strongly and from the usual everyday occupations.	This symptom is also explained by oxygen fasting fabrics.

The above symptoms appear almost in all patients with endocarditis at various stages of the disease. They do not indicate the causes of heart lesions and are mainly caused by the lack of oxygen in the tissues. According to symptoms, it is impossible to put ( and sometimes even suspect) Proper diagnosis. However, these manifestations of the disease are primarily important for patients. They talk about violations of the heart, which should be a reason for an urgent visit to the therapist or cardiologist.

The following symptoms speak in favor of infectious endocarditis:

• increasing body temperature;
• increased sweating;
• skin manifestations;
• eye manifestations;
• head and muscular pain.

Increase body temperature

Fever is observed almost in all patients with infectious endocarditis. At first, the increase in temperature may be moderate ( within subfebrisy indicators - from 37 to 37.5 degrees). However, for several days, it can rise to 39 - 40 degrees. It depends mainly on the characteristics of the causative agent of the disease. Fever appears under the influence of specific substances, pyrogen. With endocarditis in the role of pyrogen, the products of the pathogen are in favor. Finding into the blood, they affect the center of thermoregulation and increase the body temperature.

The absence or a minor increase in temperature (despite the acute infectious process) may be observed in the following groups of patients:

• elderly people;
• patients undergoing stroke;
• patients with severe heart failure;
• with an increase in the level of uric acid in the blood.

In the first phases of the disease, an increase in body temperature may not be accompanied by symptoms from the heart, which makes it difficult to formulate a diagnosis. The temperature can be held up to 3 - 4 weeks and more. At the same time, a remote type of temperature curve is noted. It is characterized by daily fluctuations in 1 - 1.5 degrees, but without decreasing normal indicators (for example, about 37.5 degrees in the morning and about 39 degrees in the evening). Against the background of the starting treatment, fever usually retreats quickly.

Chills

The chills call uncontrollable muscle contractions in the form of large trembling or small cramps. He is a typical sign of Sepsis ( circulation bacteria in blood with damage internal organs). With the endocardius of chills, it occurs mainly during the period of sharp increase in temperature.

Increased sweating

This symptom often accompanies fever. The sweat separation usually leads to a gradual decrease in the body temperature and the overall state of the patient. When sepsis, which accompanies infectious endocarditis, reinforced sweating is observed mainly at night.

Skin manifestations

Since the infection falls into the heart with blood flow, in many patients with endocarditis, it is possible to detect the damage to the vascular walls. Externally, this is manifested by a number of skin symptoms.

In patients with endocarditis, the following skin manifestations may be observed:

• Phetechial rash. Elements of rash are small red specks that do not rise above the surface. They are formed due to point hemorrhages due to the damage to the vascular wall. Rash can be localized on breasts, torso, limbs and even on mucous membranes ( solid and soft sky). In the infectious endocation in the center of point hemorrhage, a small grayish area can be located. The rash usually holds a few days, after which it disappears. In the future, repeated races may be observed without adequate treatment.
• Janeway spots. Spots are intradermal bruises of 2 - 5 mm in size, which appear on the palms or soles. They can rise above the surface of the skin on 1 - 2 mm and tack through the surface layers.
• Symptom tongue. Light skin pinch at the limb leads to the appearance of point hemorrhages. It helps to detect the brittleness of the capillaries due to the vasculitis ( vascular inflammation).
• The sample of Konchalovsky-tape-leede. This sample also proves the brittleness of the capillaries and the increased permeability of their walls. To artificially cause point hemorrhages impose a cuff or harness to the limb. Due to the reliance of surface veins in capillaries, pressure rises. A few minutes later, elements of ravis appear below.
• Nodes of Osler.This feature is typical for chronic endocardits. The nodules are dense formations on palms, fingers and soles that can reach 1 - 1.5 cm in diameter. With pressed, the patient may complain about moderate pain.

All these symptoms are not only specific for endocarditis. They may also occur with other blood diseases or vessels. However, signs of vasculitis in combination with the complaints of the cardiovascular system make it possible to assume the correct diagnosis with high degree probability.

Eye manifestations

Eye manifestations have a similar mechanism of skin appearance. Under them imply a number of symptoms associated with point bleeding in the eye area. The patient can independently notice the sign of Lukina-Libman. These are small red or pink stains on conjunctiva ( mucous membrane eyes). It is easier to detect them, pulling down the lower eyelid. On the inspection of the ophthalmologist can also discovery the stains of the company. These are sections of hemorrhage on the retina, having a pale zone in the center. They are detected when viewing the eye bottom.

Head and Muscular Pain

Head and muscle pain is characteristic of an infectious version of endocarditis. With other forms of this disease, these symptoms are usually absent or manifested slightly. Pains are associated with the general intoxication of the body due to the reproduction of microbes. Most often they coincide with the initial period of temperature rise.

Rheumatic endocarditis is characterized by signs of lesion of cardiac valves. In the early stages, patients may not make complaints. Diagnose disease is possible only with a careful examination from a cardiologist or conducting laboratory research. In the later stages, the deformation of the valves leads to the emergence of symptoms of heart failure. Distinctive features It is the rheumatic process that sometimes is the defeat of other organs and systems. This disease is rarely limited only by cardiac manifestations. In this regard, patients often impose complaints that are not characteristic of endocarditis.

With rheumatic damage to the valves, symptoms of the defeat of the following organs and systems can be observed:

• Sustaines. Inflammation of the joints can develop in parallel with endocarditis or precede it. Usually, the disease affects large and medium limb joints ( shoulder, elbow, knee, ankle). From the symptoms and complaints should be noted soreness, limiting mobility and light swelling in the field of lesion.
• Kidney.Kidney defeat with endocarditis is manifested by urine filtration disorders. In this case, signs of bleeding can appear in the blood. It is also characterized by moderate pain in the field of kidneys.
• Defeat of serous shells.In some cases, in rheumatism, such diseases may develop as pericarditis and pleurisy. This somewhat makes it difficult to diagnose endocarditis due to similar manifestations.
• Skin lesion. Typical for rheumatism are knotted and ring-shaped erythema. Sometimes rheumatoid nodules in the thicker of the skin appear. These lesions are localized mainly in the field of joints affected by the disease.

In addition, for rheumatism is not so characteristic of temperature increase. It can be observed in the early stages of the disease, but rarely exceeds 38 degrees. In addition, there are no pronounced daily fluctuations in temperature.

Diagnosis of endocarditis

For endocarditis, pronounced clinical symptoms are characterized, which allow you to quickly suspect the disease even without conducting special surveys. In particular, this concerns the bacterial endocarditis, which is richer in its manifestations. The rheumatic damage to the valve apparatus is somewhat harder.

The following research methods are applied to the diagnosis of endocardits of any origin:

• general examination of the patient;
• laboratory tests;
• bacteriological analyzes;
• instrumental examination methods.

General examination of the patient

The general examination of the patient conducts a physician for preliminary diagnosis. It can also be conducted by a cardiologist at the patient's admission to a narrowly specialized department. Inspection should include not only the study of the work of the cardiovascular system, but also the search for the extraimed manifestations of the disease.

During the general inspection, the doctor collects data on illness in the following ways:

• Collect Anamneza. Anamnese collection is very important in the diagnosis of endocarditis of any etiology, as it helps to understand where the disease came from. Most often it is possible to find out that the first heart symptoms preceded infectious diseases. Then it is possible to explain the endocarditis in the head of bacteria in the heart and the development after a while of the characteristic manifestations of the disease. With rheumatic endocardits, the first symptoms precedes an angina or pharyngitis ( usually for 2 - 4 weeks before the first signs of rheumatism). In addition, the doctor asks a patient about other chronic pathologies or transferred operations, as they can predispose to the development of endocarditis.
• Visual inspection. A visual examination of patients with endocarditis may not give almost no information. However, in infectious forms, it is possible to note the appearance of characteristic rash or other skin symptoms. With rheumatic endocarditis, respectively, inspect the patient's joints in search of signs of inflammation. In addition, patients with chronic endocarditis have overall exhaustion, pallor of skin cover, changing the shape of the fingers and nails.
• Palpation. Palpation during the heart examination almost does not allow for the diagnosis of information. If the endocarditis developed against the background of sepsis, the doctor may prove increased lymph nodes in various parts of the body. Palpation also includes the measurement of the pulse and the determination of the top shock. The latter is a point on the front breast wall, where cardiac abbreviations are projected. With the pronounced valve pathology, this point can be shifted.
• Percussion. Percussion is to perform the heart through the front pectoral wall. With its help, an experienced doctor can with high accuracy to determine the boundaries of the cardiac bag and the heart itself. Percussion is usually carried out in the position lying on the back and is a painless procedure that occupies 5 to 10 minutes. Patients with endocarditis often observes the left limit left border ( because of the hypertrophy of the muscles of the left ventricle).
• Auscultation. Auscultation is listening to heart noise through a stedlendoscope. It can provide valve information. The first auscultative changes appear usually no earlier than 2 - 3 months of the disease, when the heart disease begins to form. The most typical sign is the weakening of the first and second tones at the points of listening to mitral and aortic valves.

The above methods do not allow to judge the reasons for the appearance of symptoms. Nevertheless, according to their results, the doctor plans to further examine the patient. In case of hospitalization, it is recommended to conduct a general inspection several times a week ( if possible daily) To detect the first signs of the formation of heart defect.

Laboratory tests

Changes in laboratory analyzes with endocarditis are largely determined by the cause that caused this disease. They are one of the main sources of information and in many cases serve as sufficient argument for the diagnosis and treatment start.

In general and biochemical blood tests in patients with endocarditis, you can detect the following changes:

• Anemia. Anemia is a decrease in blood hemoglobin level to a value of less than 90 g / l. Most often it is observed with a subacute of the flow of infectious endocarditis. Anemias in these cases are normochromic ( blood color indicator in the range of 0.85 - 1.05). This indicator reflects how satrocytes are hemoglobin.
• Erythrocyte level largely depends on the severity of infection. It may be observed both its decrease and an increase. The norm for women is 3.7 - 4.7 x10 12, and for men - 4.0 - 5.1 x10 12 cells in 1 liter of blood.
• Increase the erythrocyte sedimentation rate ( Soe). This indicator changes in the first stages of the disease as the inflammatory process develops and is maintained by elevated within a few months ( even with a favorable course of the disease). The rate is up to 8 mm / h in men and up to 12 mm / h in women. With the age of the boundaries, the norms may increase to 15 - 20 mm / h. In patients with endocarditis, this indicator sometimes reaches 60 - 70 mm / h with an infectious version. Rheumatic inflammation can also lead to an increase in ESP. The normal value of this indicator with endocarditis is relatively rare, but does not exclude the diagnosis.
• Leukocytosis.The number of leukocytes in the blood is usually increased. The norm is 4.0 - 9.0 x10 9 cells per 1 liter of blood. In the case of severe bacterial endocarditis, leukopenia may be observed ( reduced leukocyte levels). So-called leukocyte formula shifted to the left. This means that young forms of cells prevail in the blood. Such changes are characteristic of the active inflammatory process.
• Disproteinemia. Disproteinemia is a violation of the proportion between blood proteins. In infectious and rheumatic endocardits, an increase in the number of gamma globulins and alpha-2-globulins may be observed.
• An increase in the concentration of sialic acids and the C-reactive factor. These indicators talk about the presence of an acute inflammatory process. They can be enhanced both in infectious and with rheumatic endocarp.
• Increased creatinine levels In biochemical analysis of blood, approximately a third of patients with infectious endocarditis is observed.
• Improving the level of sermukoid and fibrinogen Blood is celebrated with some forms of endocardits.

Most of these indicators are common to infectious and rheumatic endocarditis, which creates certain difficulties in diagnosis. Additional laboratory methods are applied to confirm these diagnoses and the choice of true treatment tactics. Checking for infectious endocarditis implies bacteriological analyzes that will be described below. To confirm the same rheumatic endocarditis, additional blood tests are carried out.

Specific analyzes to confirm rheumatic inflammation are:

• determination of the titer of anti-strohalomanonidase;
• definition of anti-rampage titer;
• definition of antistrepsin-o;
• rheumatoid factor ( antibodies against its own cells of the body, which appeared after transferred streptococcal infection).

Positive tests for rheumatic inflammation still do not exclude the infectious process. As mentioned above, the infection often develops on damaged valve flaps damaged by rheumatism ( secondary endocarditis). This creates additional difficulties in the appointment of proper treatment.

In urine analysis, there are usually no pronounced changes. With serious heart failure in the later stages of the disease, Oliguria may be observed ( reduced urine formation). It is explained by the weakening of the pumping function of the heart, because of which the pressure required for normal filtration is not supported in the kidneys. In rheumatism with the damage to the kidney tissue in the urine there may be traces of blood.

Bacteriological analyzes

Bacteriological analysis is aimed at identifying the causative agent of the disease in infectious endocarditis. The material for the study is blood, as it is washes all the chambers of the heart and in contact with microorganisms directly. Given the large number of possible pathogens, a number of rules should be observed when taking blood. They help to avoid incorrect result and gain reliable information about the causative agent of the disease.

When taking blood for bacteriological sowing, followed by the following principles:

• With acute endocarditis, three blood samples are taken with an interval in half an hour. With a subacute flow, it is possible to take three samples during the day. Repeated crops increase the reliability of the study. The fact is that on the nutrient medium can grow and microbes that accidentally fall into the sample. Triple study eliminates the likelihood of such accidental pollution.
• With each puncture of the veins, 5-10 ml of blood takes. Such a large amount is explained by the fact that the concentration of bacteria in the blood is usually very small ( 1 - 200 cells in 1 ml). A large amount of blood increases the likelihood that bacterium will grow on a nutrient medium.
• It is advisable to take blood for the analysis before the start of antibiotic therapy. Otherwise, the reception of antimicrobial drugs will strongly reduce the activity of bacteria and reduce their concentration in the blood. The result will be a false negative analysis. If the patient is not critical, even the temporary cessation of antibiotic therapy for bacteriological sowing of blood is practiced.
• Blood fence is made only in sterile gloves with sterile disposable syringes. The skin at the venue puncture is treated with an antiseptic solution twice, because it is especially high, the concentration of microbes that can contaminate the sample are particularly high.
• The blood obtained is immediately delivered to the sowing laboratory.
• If the colonies do not grow on nutrient media within 3 days, the analysis can be repeated.

When a culture is obtained on the nutrient medium, the microbial is identified and the antibioticogram is made. This is a separate study that shows which drugs are most effective against a specific causative agent. Approximately 25 - 30% of cases, it is not possible to highlight the pathogen of the disease.

An alternative to bacteriological analysis is the conduct of serological tests. They determine the presence of antibodies in various microbes or directly microbial antigens are detected. The disadvantage of such a study is that there is no possibility to make an antibioticogram.

Instrumental examination methods

In the diagnosis of endocarditis, the instrumental methods of examination occupy a very important place. They are aimed at visualizing the structure or work of the heart in one way or another. These methods help in early stages determine the cause of the disease and recognize the threat of complications.

The following instrumental diagnostic methods have the greatest value at endocarbage:

• Electrocardiography ( ECG). Electrocardiography is based on measuring the strength and direction of bioelectric pulses in the heart. This procedure Fully painless, takes 10 - 15 minutes and allows you to immediately get the result. With endocarditis in the early stages of the disease, changes to the ECG will be present only at 10 - 15% of cases. They are expressed in violations of the reduction of the heart muscle, instability heart Rhythm and signs of myocardial ischemia ( lack of oxygen). These changes are not specific and more often indicate the availability of certain complications of endocarditis.
• Echocardiography ( Ehoche). This method is based on the penetration of ultrasonic waves into the thickness of soft tissues of the heart. Reflecting on the structures of different density, these waves return to a special sensor. As a result, an image is formed. It can be noted vegetation or forming clomes characteristic of endocarditis. In addition, the locations of the battle of the valves and the characteristics of the deformation of their sash are visible. EchoCG is recommended to be repeated at various stages of the disease to recognize the first signs of heart defects.
• Radiography. When radiography, the image is obtained by passing x-ray rays Through the chest. It is impossible to find specific for endocarditis of changes. However, this method allows you to quickly see the stagnation in a small circle of blood circulation and an increase in the heart in the amount. The study is appointed when the first appeal to the doctor to detect signs of cardiac pathology as a whole.
• Ultrasound procedure ( Ultrasound), CT scan ( Kt.) and magnetic resonance therapy ( MRI). These studies are not so often used to diagnose directly endocardits due to its high cost ( CT and MRI). However, they are indispensable in search of complications of this disease. In particular, we are talking about the tomb clocks. They can block the arteries of the limbs, internal organs or even the brain, creating a serious threat to the patient's life and health. For urgent treatment, it is necessary to determine the exact localization of blood cloth. In this and can help heart ultrasound, CT and MRI. Sometimes they are also used to detect articular changes during rheumatism, which helps in diagnosis.

Based on the above diagnostic methods, special criteria were created to diagnose endocarditis. First of all, they are used to confirm the infectious forms of this disease. Guided by an uncomplicated algorithm, the doctor can put the correct diagnosis and begin treatment in more than 90% of cases.

Generally accepted criteria for the diagnosis of bacterial endocarditis

Large criteria	Small criteria
In two of the three blood sampling, a typical endocarditis causative agent is revealed ( green Streptococcus, Golden Staphylococcus, Hacek Group Bacteria).	The presence of risk factors for infectious endocarditis ( congenital heart defects, artificial valves, drug use injecting, etc.).
Bacteremia confirmed by blood tests with an interval of 12 hours.	Increase body temperature more than 38 degrees.
Movable vegetations on echochegte or abscess fibrous valve ring.	Patechial rash or thrombosis of the arteries of internal organs.
Pronounced valve failure ( also evaluated using Ehoche).	Detection of rheumatoid factor and other extraimedar signs of rheumatism.
	Positive analysis When sowing one of the three basic blood samples.

It is believed that in order to confirm endocarditis, a patient should have 2 large criteria, 1 large and 3 small or all 5 small criteria. In this case, the appointment of specific treatment is possible without further diagnostic tests.

One of the serious problems in the diagnosis of endocarditis is the identification of its root cause in the early stages of the disease. Doctors often have to decide whether they are dealing with infection or with rheumatic inflammation. The fact is that treatment in these two cases will be different. The correct diagnosis in the initial stages will allow to begin medical therapy earlier, which will prevent complications and eliminate the threat to the patient's life.

The main differences between the bacterial and rheumatic endocarditis

Symptom or diagnostic test	Infectious endocarditis	Rheumatic endocarditis
Accompanying illnesses	Often develops after acute infectious diseases or simultaneously with them ( sinusitis, surgical interventions, gOOD INFECTION, pneumonia, etc.).	Can develop on the background chronic tonsillita Or after transferred scarletin.
Fever	Temperature can rise to 38 - 40 degrees and change greatly during the day.	The temperature rarely exceeds 38 - 38.5 degrees and is not prone to quick drops.
Symptoms accompanying fever	Often, a strong chill is observed, abundant sweating ( especially at night).	These symptoms are rarely observed.
Embolia	There are quite often found.	Not characteristic, observed only against the background of serious rhythm violations.
Symptom of "drum sticks"	For chronic flow Diseases fingers relatively quickly change the form.	The symptom appears only with pronounced valve defects.
Typical changes in blood test	Anemia, thrombocytopenia ( lowering platelet levels), increased levels of leukocytes.	Anemia is rare. Leukocytosis is more characteristic than leukopenia.
Bacteriological research	Repeated blood sown most often ( 70% of cases) give repeated positive results for the same microorganism.	Sowing blood does not reveal the pathogens.
Changes on Ehocheg	Often it is possible to distinguish between vegetation on cardiac valve flaps.	Vegetations are not detected.
Reaction to the use of antibiotics.	The patient's condition begins to improve already on 2 - 3 days of treatment.	There are no pronounced changes in the patient state.

As a rule, neither one of the above symptoms or research is impossible to accurately determine the origin of the endocarditis. However, the complex assessment of the patient's condition and the comparison of all manifestations of the disease contribute to the setting of the correct diagnosis.

Treatment of endocarditis

The tactics of the treatment of endocarditis directly depends on its type. If the infectious nature is suggested that the patient's mandatory hospitalization is shown to clarify the diagnosis. This is explained by relatively high mortality from frequent complications. The patient is discharged to continue treatment at home, if during the hospital in the hospital his condition did not deteriorate and managed to put the final diagnosis. On average, hospitalization is required for 1 to 2 weeks with a favorable course of the disease.

Depending on the type of illness and leading symptoms, treatment can be carried out in the rheumatological, infectious or cardiovascular branch. Consultation of the cardiologist is shown in any form of endocarditis. With this specialist, it is obligatory to coordinate the course of treatment.

Immediately the treatment of endocardits is largely determined by the disease stage and nature of the inflammatory process. The erroneous diagnosis often leads to incorrect treatment. Medical errors are recognized as the most common cause of chronic infectious endocardits.

The following methods are used in the treatment of endocarditis:

• conservative treatment;
• surgery;
• prevention of complications.

Conservative treatment

Conservative treatment It implies the use of various medicines to eliminate the causes of the disease and its main symptoms. In most cases, they are resorted to drug therapy, which is sufficient for complete recovery. The principles of treatment and the drugs used are distinguished in the case of an infectious and rheumatic process.

Treatment of acute infectious endocarditis involves taking antibiotics to destroy the causative agent of the disease. Antimicrobial preparations are prescribed after 1 - 2 hours after the admission of patients, immediately after taking blood to bacteriological analysis. Before receiving the results of this analysis ( usually a few days) The patient takes the drug chosen empirically. The main requirement for it is wide spectrum actions. After determining the specific pathogen, the corresponding drug is prescribed.

Antibiotics used in the treatment of bacterial endocarditis

Revealed pathogen	Recommended drugs	Dosage preparations and reception mode
Green Streptococcus ( Streptococcus Viridans)	Bezylpenicillin	2 - 3 million units of the drug 6 times a day intravenously ( v / B.) or intramuscularly ( v / M.). The course of treatment lasts 4 weeks.
	Ceftriaxon	2 g 1 time per day in / in or per / m for 4 weeks.
	Ampicillin	2 g 4 - 6 times a day in / in or per / m for 4 weeks.
	Gentamicin	3 mg per 1 kg of body weight ( if the patient does not suffer obese). It is introduced in / in or per / m 1 - 3 times a day. The course of treatment is 4 weeks.
	Amoxicillin / Clawulanic Acid	1.2 - 2.4 g 3 - 4 times a day in / in or per / m for 4 weeks.
Golden Staphylococcus ( Staphylococcus aureus)	Oxacillin	2 g 6 times a day in / in or per / m within 4 - 6 weeks.
	Cefasoline	2 g 3 - 4 times a day in / in or per / m within 4 - 6 weeks.
	Imipenem	0.5 g 4 times a day in / in or per / m for 4 - 6 weeks.
	Vancomycin	1 g 2 times a day in / in within 4 - 6 weeks.
	Linezolid
Enterococci ( Enterococcus)	Bezylpenicillin	4 - 5 million units of the drug 6 times a day in / c for 4 - 6 weeks.
	Ampicillin
	Gentamicin
Pneumococcus ( Streptococcus Pneumoniae)	Linezolid	0.6 g 2 times a day in / c for 4 - 6 weeks.
	Cefotaxim	2 g 6 times a day in / c for 4 - 6 weeks.
	Levofloxacin	0.5 g 1 time per day in / c for 4 - 6 weeks.
Pathogens from the group Hacek.	Ceftriaxon	2 g 1 time per day in / c for 4 - 6 weeks.
	Ampicillin	2 g 6 times a day in / c for 4 - 6 weeks.
	Gentamicin	3 mg per 1 kg of body weight 1 - 3 times a day in / c for 4 - 6 weeks.
Sinnaya stick ( Pseudomonas Aeruginosa)	Ceftazidim	2 g 2 - 3 times a day in / c for 4 - 6 weeks.
Fungal infections	Amicacin	0.5 g 2 times a day in / c for 4 - 6 weeks.
	Meropem	1 g 3 times a day in / c for 4 - 6 weeks.
	Amphotericin B.	0.5 mg per 1 kg body weight per day in / in.
	Flucitozin	100 - 200 mg per 1 kg of body weight per day in / c.

All of the above antibiotics apply only to the appointment of the attending physician. Such a long-term course of antibiotic therapy can give many side effects from various organs and systems, so self-treatment is prohibited. By necessity, the attending physician appoints a combination of several drugs. In some cases, the course of treatment can be extended to 8 weeks.

To end the course of treatment and cancellation of antibiotics, compliance with the following criteria:

• persistent normalization of body temperature;
• lack of growth of colonies when cropping;
• disappearance of sharp clinical symptoms and complaints;
• reducing the level of soe and other laboratory indicators to normal.

In the treatment of rheumatic inflammation of the endocardium ( rheumokard) Antibiotics also apply. However, in this case, their task is to complete the destruction of beta-hemolytic streptococcus, which gave the beginning of the inflammatory response. For this purpose, benzylpenicillin intramuscularly prescribed at a dose of 1.5 - 4 million units per day in 4 administration. The course of treatment lasts 10 days.

Further treatment is aimed at eliminating the actual inflammatory process. This use glucocorticosteroid drugs. The standard treatment diagram includes prednisone 20 mg per day. The drug is accepted after breakfast in one sitting inside ( in the form of a tablet). Glucocorticosteroid drugs are used in order to bring down acute inflammation with other forms of endocarditis. The main purpose of their reception is to prevent the formation of heart defect.

In addition to the antimicrobial and anti-inflammatory treatment, aimed at the causes that cause endocarditis, patients often prescribe a number of cardiac drugs. They help restore the pumping function of the heart and struggle with the first signs of heart failure.

To maintain normal operation of the heart in patients with chronic endocarditis, the following groups of drugs are used:

• angiotensin surgery enzyme inhibitors;
• aldosterone antagonists;
• beta blockers;
• diuretics ( diuretics);
• heart glycosides.

The main effect of these drugs is to reduce the load on the heart and improve its work. Final choice drug And its dosage is carried out by a cardiologist, depending on the severity of the heart disease and the type of endocarditis.

Surgery

The main goal of surgical treatment with endocarditis is the rapid prevention of hazardous complications. In addition, through the operation, some irreversible defects that developed due to endocarditis can be eliminated. Given the patient's severe condition, surgical treatment is carried out strictly by certain indications.

Indications for surgical treatment of endocarditis are:

• increasing heart failure, which is not possible to adjust drugs;
• magnification in the field of endocardium ( in the thickness of myocardium or near the fibrous rings of the valve);
• bacterial endocarditis in people with a mechanical heart valve;
• massive vegetation on valve flaps ( high risk of thromboembolia).

Operational access to the organ is carried out using thoracotomy ( opening of the chest). As soon as access to the patient's heart is obtained, it is connected to the artificial circulation apparatus, which will perform a pumping function for blood during the operation. After the blood supply to the fabrics has been established, the surgeon begins a rejection ( cleaning) Hearts.

Sanitation of the infectious hearth with endocarditis consists of three stages:

• mechanical Sanation - the removal of vegetation is carried out, as well as irreversibly affected structures and valves;
• chemical sanitation - processing chambers of the heart with an antiseptic;
• pHYSICAL SANATION - processing inaccessible to the removal of tissues by low-frequency ultrasound.

After that, a decision is made to replace damaged valves with artificial. As a rule, a separate operation is carried out for this. The need for an artificial valve occurs in 10 - 50% of patients at a certain stage of the disease ( depends on the type of microorganisms and the effectiveness of the treatment).

In the case of bacterial endocarditis, even an open surgical sorry of the heart does not always guarantee the complete destruction of infection. Therefore, surgical treatment in no way implies the abolition of a medication course of treatment. It is only a supplement to achieve a faster effect and correction of irreversible violations.

Prevention of complications

The prevention of complications of endocarditis is reduced to compliance by the prescribed course of treatment. With the emerging heart defects, it is important to limit physical exertion and stress. The more the heart is loaded, the faster the irreversible changes in its valves will occur.

An important element of prevention is proper nutrition. Diet with endocarditis is not very different from a diet with any other cardiovascular disease ( diet number 10 and 10a). These power modes are aimed at reducing the load on the heart and the prevention of atherosclerosis. The latter can lead to a narrowing of coronary arteries and deterioration of myocardial oxygen.

Diet number 10 recommends limiting salt eating ( no more than 5 g per day), fatty and sharp products, alcohol. All these products directly or indirectly increase the load on the heart muscle and exacerbate heart failure.

Patients who have endured endocarditis either undergoing treatment is recommended to use the following products:

• bran bread;
• non-fat soups;
• boiled meat or fish;
• vegetables in any form;
• pasta;
• most confectionery products ( with the exception of black chocolate);
• milk and dairy products.

The combination of this diet with a regular visit to a cardiologist will help avoid recurrence of the disease. With the formated heart defects, this will reduce discomfort from the present heart failure.

Consequences and complications of endocarditis

Even with rapid recovery in patients with acute infectious endocarditis, serious complications and the consequences of this disease may be observed. Some of them cause minimal discomfort in everyday life, but others are a serious danger to life. In this regard, after discharge from the hospital, the doctor necessarily warns the patient about possible complications and methods of combating them.

The main consequences and complications of endocarditis are:

• chronic heart failure;
• thromboembolia;
• tightening infectious process.

Chronic heart failure

Chronic heart failure is a satellite of many heart disease. It represents a pathological condition in which the heart cannot provide a normal amount of blood. With endocarditance, this is due to the impairment of the reduction of the heart muscle, a decrease in the volume of cardiac cameras, but most often - with violations in the valve apparatus. The narrowing of the valve or, on the contrary, the spinning of its sash leads to blood flow disorders from one heart separation into another. At the level of the body, this is manifested by the advent of heart failure.

This problem can be solved by implanting the artificial valve of the heart. If you have completely cured endocarditis, destroying the valve, the forecast for such patients remains favorable.

Thromboembolia

Thromboembolia is called the blockage of the artery with a broken thrombus. This complication is the most common cause of death in patients with endocarditis. The thrombus can be formed on a valve sash in the form of a moving vegetation or gradually grow in an adrenched endocardium. One way or another, he can break away and get into the bloodstream.

If the thrombus was formed in the right ventricular departments, it falls into a small circle of blood circulation. Here he gets stuck in the vascular network of the lungs, disturbing gas exchange. Without urgent help, the patient quickly dies. Such a tombalization of the tomb is called pulmonary artery thromboembolism.

If the thrombus is formed in the left hearts, it enters a large circle of blood circulation. Here it can be stuck in almost any part of the body, causing the corresponding symptoms. When blocking the arteries of internal organs or brain almost always there is a danger to the patient's life. If the artery is clocked in the limb, it can lead to the death of fabrics and amputation.

The most often clomes from the left ventricle lead to the blockage of the following vessels:

• artery spleen;
• brain artery ( with the development of stroke);
• arteries of the limbs;
• mesenteric arteries ( with impaired intestinal blood supply);
• artery retina eye ( leads to irreversible loss of vision (blindness)).

Due to the high risk of thromboembolism, doctors try to appoint EchoCG to all patients with endocarditis. When moving rolling vegetations or forming thrombus, their surgical removal or drug prevention of this complication is carried out.

Tightening infectious process

Since the heart rate with bacteria is located in the heart with infectious endocardium, it can cause bacteriamia resistant. Depending on the number of microorganisms and their kind, it provokes serious complications. Long-term circulation of microbes in the blood maintains a feverish state and is the risk of separation of infection to other organs and tissues. Endocarditis, being a consequence of sepsis, at the same time supports it, making it difficult. This explains the need for long and expensive treatment. The patient for a long time after the disappearance of cardiac symptoms suffers from subfebrile temperature, total weakness, head and muscle pain.

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Endocarditis - a disease that affects the inner sheath of the heart, as well as aortic and heart valves. This serious, threatening pathology is characterized by rapid development, the danger of the embolus of blood vessels, internal vital organs and the development of immunopathological processes.

Endocardits are divided into infectious (bacterial) and noncommunicable. Although in the overwhelming majority of cases, endocardits are infectious in nature, there are pathologies developing as a reaction to metabolic changes in the framework of the immunopathological process or with mechanical damage to the heart.

Unconfecting endocardits include:

• Atypical warthy endocarditis with;
• Rheumatic endocarditis;
• Endocardits with rheumatoid, reactive arthritis;
• Fibroplastic endocarditis Leffer;
• Nebacterial thrombotic endocarditis.

Almost always, the above-mentioned diseases are an indicator that the risk of developing infectious endocarditis (IE) in these cases is extremely high, namely, it represents the greatest danger to the life of the patient.

Causes of infectious endocarditis

The disease occurs infrequently, but recently there has been a steady tendency to increase the development cases of IE, which is associated with increasing resistance (resistance) of bacterial microflora to antibiotics as a result of mutations. Another reason for the growth of the number of septic endocarditis is an increase in the number of people taking intravenously narcotic substances.

Most often pathogenic gram-positive microorganisms are most often pathogens: in most cases it is staphylococcus, streptococcal, enterococcal infections. It is much less likely to develop other microorganisms, among which gram-negative bacteria may be, rare atypical pathogens and fungal infections.

The lesion of the heart shell during IE occurs with bacteremia. The concept of "infectious endocarditis" is synonymous with such definitions as septic or bacterial endocarditis. Bacteremia (the presence of blood bacteria) is capable of developing under favorable conditions even after the most innocuous procedures.

Treatment with high risk of development of bacteriamia are:

1. Dental operations with damage to the mucous membranes of the oral cavity and gums;
2. Performance of bronchoscopy when using hard tools;
3. Cystoscopy, manipulation and operational interventions on the organs of the urinary system, if there is an infectious component;
4. Conducted biopsy of the urinary channel or prostate gland;
5. Operation on the prostate gland;
6. Adenoid methods, tonsillectomy (removal of almonds and adenoids);
7. Operations carried out on biliary tract;
8. Previously conducted lithotripsy (destruction of stones in the kidneys, urinary, bustling bubble);
9. Gynecological operations.

Cardiologists allocate risk groups with endocardium inflammation prerequisites for which antimicrobial therapy is necessary for endocarditis prophylaxis.

The high risk group includes:

• Patients who have previously overlooking bacterial endocarditis;
• Operated on for the prosthetics of the heart valve, if mechanical or biological materials were used;
• Having congenital and acquired complex disorders relating to the aorta, heart ventricles - the so-called "blue" vices;

The following categories of patients are subject to moderate risk:

• Patients with;
• With hypertrophic;
• Having any other heart defects (congenital and acquired), not falling into the first risk group, without cyanosis.

Less than other dangers of developing this disease are patients with the following diagnoses:

• and vessels;
• The defect of the interpidential I. interventricular partition, including those operated on, in the period up to six months after surgery;
• Implanted pacemakers and defibrillators;
• without damping valves.

Video: endocarditis. Why is it so important to treat your teeth on time?

How does the development of IE?

The period from the penetration of infection to the development of the IE clinic is different - from several days to several months. It depends on the virulence of the pathogen, the state immune system Patient and Hearts.

Inside the cavity of the heart, the causative agent settles on the valve flaps and begins to grow, while colonies of microorganisms (vegetation) are formed. In addition to microorganisms, there are red blood cells, leukocytes, thrombocytes, fibrin. As infection develops, the surface of the valves is deformed, forming a bug surface or ulcers with thrombotic overlay.

When the deformation reaches significant sizes, heart valves lose the ability to clog tightlyWhat leads to the development of hemodynamic disorders and the emergence of acute heart failure. This condition develops rapidly and carries the danger to the life of the patient. From the destroyed valve, destroyed pieces of flaps, fragments of colonies of microorganisms can be broken. With the blood current, they are spread over a small and large circulation of blood circulation, they can cause ischemia of important organs and, which is accompanied by various neurological disorders, paresses and paralysis and other serious complications.

Endocarditis classification

When diagnosing a diagnosis, the doctor should formulate a refined diagnosis characterizing the main features inherent in this type of disease, which allows you to make a more accurate and detailed idea of \u200b\u200bthe course of the disease.

1. The activity of the pathological process is distinguished by active, cured, recurrent endocarditis;
2. By probability and definiteness of the diagnosis (probable or defined);
3. By type of infectious pathogen (defined or not established);
4. By the nature of the damaged valve, if the prosthetics occurs.

There are also several types of flow and severity of the inflammatory process, taking into account the initial characteristics of damaged valves.

• Acute septic endocarditis is able to develop for a matter of hours or days, it is characterized by a pronounced hectic fever, the rapid development of complications in the cardiovascular system. The acute IE and the pronounced ability to penetrate the surrounding tissues, which is due to the type of pathogen with high levels virulence;
• Subighteous infectious endocarditis develops slower, from the penetration of the causative agent into the cavity of the heart to clinical manifestations It takes from a few weeks to several months. Its more favorable, since its pathogen is less aggressive and is capable of penetrating the surrounding tissues.

In addition, the disease is classified for the following types:

1. Primary IE - the initially intact endocardia is affected;
2. Secondary IE - is able to develop against the background of the existing heart pathology.
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