**2. Epidemiology**

As discussed above, the areas of greatest focus are currently the implications of the global intravenous drug abuse (IVDA) epidemic and the growing utilization of cardiac implantable devices (CID). Both of these very different set of problems has each contributed to a substantial increase in the incidence of endocarditis and, particularly, involving right-sided cardiac structures such as the tricuspid valve. While there is extensive literature and guidelines for the diagnosis and management of left-sided disease (i.e. aortic and/or mitral valves), the literature for the diagnosis and treatment of right-sided disease is still evolving and will reviewed in several of the chapters of this text. It is not just the medical difficulties in the management of IVDA associated endocarditis that continues to be a problem, but the social and ethical implications for re-infections in patients who continue to abuse drugs or fail to pursue appropriate definitive therapy [3, 4]. The recognition of this growing problem is only slowly being better understood [5]. In addition, as mentioned, with the growing utilization of advanced cardiac therapies and implants, there is also a growing risk and incidence of device-related infectious complications [6, 7]. Unfortunately, the increasing use of such devices is expanding at a rate that is exceeding the healthcare systems ability to better understand how to prevent, diagnosis, and treat such device related infections [8–10]. However, with the development and expansion of "Heart Team" to better guide therapies and management, there exist increasing opportunities to improve outcomes by incorporating a team-based approach to the management of these very difficult problems.

## **3. Diagnosis**

Positive blood cultures are the *sine quo non* in establishing a diagnosis of endocarditis. In addition, the original Dukes Criteria has been used for many years to further help make the diagnosis [11]. Advances in ultrasound imaging has shown to be extremely useful in the management of patients and guiding therapy [12]. Transthoracic and transesophageal imaging are considered first-line tests to evaluate for suspected endocarditis. Current major international society guidelines and appropriateness criteria support their liberal use [2, 12] – the role of other modalities, such as 3D echocardiography, computed tomography (CT), magnetic resonance imaging, and positron-emission tomography (PET) continues to expand [13, 14]. Nevertheless, such diagnostic tools should be readily available and aggressively used, including non-cardiac imaging of the neuro-axis and body structures, to ensure the scope of what is typically a systemic problem is completely defined. Furthermore, any change in the clinical picture or concerns for disease progression or failure of medical therapies should prompt a timely reassessment with repeat imaging.

### **4. Therapy**

Without a doubt the cornerstone to early managed is focused on targeted antibiotic therapies, diagnosis of the primary problem, evaluation for secondary complications (such as embolic complications, like stroke), and engagement of a multi-disciplinary team of physicians and healthcare providers, who, by definition have both an interest and expertise in endocarditis to help define a treatment plan. As with any treatment plan, the recipe for success must consider if and when

**3**

*Introductory Chapter: Endocarditis*

be revised [15–18].

specifically [19]:

in particular, fungal infections.

evidence of recurrent embolic complications.

*DOI: http://dx.doi.org/10.5772/intechopen.98747*

surgery should be performed (and which operation – not an easy decision process) and how some of the contributing co-morbidities can be attenuated to minimize the risks for recurrence. While it is easy to focus on the initial diagnosis and managed, often an index hospitalization, long-term success requires close follow-up to monitor for compliance to optimize the opportunity an overall successful treatment plan. Because of the challenges of many of the socio-economic problems that patients with endocarditis often face, and are addressed in some of the chapters of this text, full engagement by the entire healthcare team will need to make sure that any and all obstacles to treatment success are removed, if possible. An extensive medical and surgical plan that does not consider the socio-economic variables that are often

One of the most important decisions in the management of endocarditis is determining the role of surgery – and not just if surgery should be performed, but when, what operation, choices of valves, risks for complications, barriers to follow-up (i.e. need for life-long anticoagulation if mechanical valves are used), and maybe even where and by whom. Such decision making cannot and should not be performed in the vacuum of specific guidelines and indications for surgery but also must consider the entire evolving clinical picture. Regardless of the direction of the care plan, recognition of the impact on timing of therapies is of critical importance. As with most medical problems, delays in therapy might make the problem worse and hence require not just a broad understanding of the evolving literature regarding the timing of surgery, but the importance of timely evaluation of problems, regardless of how trivial they may appear and constant re-assessment of the treatment plan to ensure the original plan is working as planned as does not need to

A common theme in many of these chapters is the decision-making process and role for surgery. A point that requires further emphasis is the role for early surgery and how this concept needs to cage every aspect of a larger treatment plan,

1.Early surgery is recommended in patients with highly-resistant organisms and,

2.Worsening heart failure (especially acute) due to valvular dysfunction.

3.New or worsening cardiac complications – such as root abscesses, fistulas, heart block, and evidence of new/worsening annular involvement.

4.Surgery is indicated with failure of medical therapy, such as persistent bacteremia or septic symptoms (fever, tachycardia) greater than 5–7 days in the absence of another causes in the setting of targeted antibiotic management.

5.Growing vegetations despite appropriate antibiotic therapy – especially with

6.Large and/or mobile vegetations (>1 cm) and/or with severe valve regurgita-

Unfortunately, such decision-making and indications often mandates surgery in less than optimal conditions – such as patients who are still actively infected, have sustained recent systemic or cerebral embolic complications, or are risk for longterm reinfection due to compliance or concerns of co-existing and incompletely addressed or defined comorbidities. Such is the realities of this disease process

tion – even in the absence of heart failure signs and symptoms.

unique to each patient are probably at risk for treatment failure.

#### *Introductory Chapter: Endocarditis DOI: http://dx.doi.org/10.5772/intechopen.98747*

*Advanced Concepts in Endocarditis - 2021*

As discussed above, the areas of greatest focus are currently the implications of the global intravenous drug abuse (IVDA) epidemic and the growing utilization of cardiac implantable devices (CID). Both of these very different set of problems has each contributed to a substantial increase in the incidence of endocarditis and, particularly, involving right-sided cardiac structures such as the tricuspid valve. While there is extensive literature and guidelines for the diagnosis and management of left-sided disease (i.e. aortic and/or mitral valves), the literature for the diagnosis and treatment of right-sided disease is still evolving and will reviewed in several of the chapters of this text. It is not just the medical difficulties in the management of IVDA associated endocarditis that continues to be a problem, but the social and ethical implications for re-infections in patients who continue to abuse drugs or fail to pursue appropriate definitive therapy [3, 4]. The recognition of this growing problem is only slowly being better understood [5]. In addition, as mentioned, with the growing utilization of advanced cardiac therapies and implants, there is also a growing risk and incidence of device-related infectious complications [6, 7]. Unfortunately, the increasing use of such devices is expanding at a rate that is exceeding the healthcare systems ability to better understand how to prevent, diagnosis, and treat such device related infections [8–10]. However, with the development and expansion of "Heart Team" to better guide therapies and management, there exist increasing opportunities to improve outcomes by incorporating a team-based approach to the management of these

Positive blood cultures are the *sine quo non* in establishing a diagnosis of endocarditis. In addition, the original Dukes Criteria has been used for many years to further help make the diagnosis [11]. Advances in ultrasound imaging has shown to be extremely useful in the management of patients and guiding therapy [12]. Transthoracic and transesophageal imaging are considered first-line tests to evaluate for suspected endocarditis. Current major international society guidelines and appropriateness criteria support their liberal use [2, 12] – the role of other modalities, such as 3D echocardiography, computed tomography (CT), magnetic resonance imaging, and positron-emission tomography (PET) continues to expand [13, 14]. Nevertheless, such diagnostic tools should be readily available and aggressively used, including non-cardiac imaging of the neuro-axis and body structures, to ensure the scope of what is typically a systemic problem is completely defined. Furthermore, any change in the clinical picture or concerns for disease progression or failure of medical therapies should prompt a timely reassessment with repeat

Without a doubt the cornerstone to early managed is focused on targeted antibiotic therapies, diagnosis of the primary problem, evaluation for secondary complications (such as embolic complications, like stroke), and engagement of a multi-disciplinary team of physicians and healthcare providers, who, by definition have both an interest and expertise in endocarditis to help define a treatment plan. As with any treatment plan, the recipe for success must consider if and when

**2. Epidemiology**

very difficult problems.

**3. Diagnosis**

**2**

imaging.

**4. Therapy**

surgery should be performed (and which operation – not an easy decision process) and how some of the contributing co-morbidities can be attenuated to minimize the risks for recurrence. While it is easy to focus on the initial diagnosis and managed, often an index hospitalization, long-term success requires close follow-up to monitor for compliance to optimize the opportunity an overall successful treatment plan. Because of the challenges of many of the socio-economic problems that patients with endocarditis often face, and are addressed in some of the chapters of this text, full engagement by the entire healthcare team will need to make sure that any and all obstacles to treatment success are removed, if possible. An extensive medical and surgical plan that does not consider the socio-economic variables that are often unique to each patient are probably at risk for treatment failure.

One of the most important decisions in the management of endocarditis is determining the role of surgery – and not just if surgery should be performed, but when, what operation, choices of valves, risks for complications, barriers to follow-up (i.e. need for life-long anticoagulation if mechanical valves are used), and maybe even where and by whom. Such decision making cannot and should not be performed in the vacuum of specific guidelines and indications for surgery but also must consider the entire evolving clinical picture. Regardless of the direction of the care plan, recognition of the impact on timing of therapies is of critical importance. As with most medical problems, delays in therapy might make the problem worse and hence require not just a broad understanding of the evolving literature regarding the timing of surgery, but the importance of timely evaluation of problems, regardless of how trivial they may appear and constant re-assessment of the treatment plan to ensure the original plan is working as planned as does not need to be revised [15–18].

A common theme in many of these chapters is the decision-making process and role for surgery. A point that requires further emphasis is the role for early surgery and how this concept needs to cage every aspect of a larger treatment plan, specifically [19]:


Unfortunately, such decision-making and indications often mandates surgery in less than optimal conditions – such as patients who are still actively infected, have sustained recent systemic or cerebral embolic complications, or are risk for longterm reinfection due to compliance or concerns of co-existing and incompletely addressed or defined comorbidities. Such is the realities of this disease process

and all providers must recognize that sometimes earlier intervention, even if in less-than-ideal surgical conditions, might be ultimately better for the patient in the long run.

Similar considerations are used to guide the management of prosthetic valve endocarditis [20]. Despite the challenges of re-operative surgery in a "septic" patient, it must be appreciated that medical therapies alone are rarely successful, the best opportunity for a cure often requires complete removal of all prosthetic material and replacement.
