Hemodynamic Complications in Infective Endocarditis

  • Bernard Iung


Heart failure complications in infective endocarditis (IE) are mainly due to acute valvular regurgitation secondary to valve destruction. The pathophysiology of acute AR accounts for particularities in clinical and echocardiographic presentation which may represent diagnostic pitfalls. Acute regurgitations are poorly tolerated due to the lack of left ventricular adaptation. Heart failure occurs in approximately a third of patients with IE and is strongly associated with an increase in early and late mortality. Despite the lack of randomized trials, a large body of evidence shows that early surgery improves the prognosis of patients with heart failure, as attested by guidelines. However, decision-making is difficult during acute IE and it is likely that certain patients with IE and heart failure are denied surgery without appropriate risk-benefit analysis. Heart failure after the acute phase of IE also has a negative prognostic impact and highlights the need for careful follow-up.


Endocarditis Heart failure Cardiogenic shock Acute regurgitations Echocardiography Prognosis Valvular surgery Risk-stratification 



Aortic regurgitation


B-type natriuretic peptide


International collaboration on infective endocarditis


Infective endocarditis


New York Heart Association


Mitral regurgitation

Supplementary material

324212_1_En_9_MOESM1_ESM.avi (66.4 mb)
Video 9.1 Endocarditis on a native mitral valve. Transesophageal echocardiography: perforation of the anterior leaflet with two adjacent vegetations (left panel) and severe mitral regurgitation (right panel). See also Fig. 9.1a, b (AVI 68004 kb)
324212_1_En_9_MOESM2_ESM.avi (63.1 mb)
Video 9.2 Mycotic endocarditis (candida) on an aortic bioprosthesis. Transthoracic echocardiography, parasternal short-axis view: severe periprosthetic aortic regurgitation originating from a large periprosthetic abscess (AVI 64604 kb)
324212_1_En_9_MOESM3_ESM.avi (69.7 mb)
Video 9.3 Mycotic endocarditis (candida) on an aortic bioprosthesis. Transesophageal echocardiography: severe periprosthetic aortic regurgitation along the anterior leaflet of the mitral valve. See also Fig. 9.2a–c (AVI 61204 kb)
324212_1_En_9_MOESM4_ESM.avi (59.8 mb)
Video 9.4 Mitral endocarditis with eccentric regurgitant jet swirling in left atrium secondary to paracommissural prolapse of the anterior leaflet (A3). Transthoracic echocardiography, 2-chamber apical view (AVI 71404 kb)
324212_1_En_9_MOESM5_ESM.avi (66.4 mb)
Video 9.5 Mitral endocarditis with eccentric regurgitant jet swirling in left atrium secondary to paracommissural prolapse of the anterior leaflet (A3). Transesophageal echocardiography. See also Fig. 9.3a, b (AVI 68004 kb)
324212_1_En_9_MOESM6_ESM.avi (159.4 mb)
Video 9.6 Endocarditis on a bicuspid aortic valve. Transesophageal echocardiography: prolapse of the anterior aortic cusp and vegetations on both aortic cusps (AVI 163256 kb)
324212_1_En_9_MOESM7_ESM.avi (60.2 mb)
Video 9.7 Endocarditis on a bicuspid aortic valve. Transesophageal echocardiography: severe aortic regurgitation. See also Fig. 9.4a–d (AVI 61607 kb)


  1. 1.
    Stout KK, Verrier ED. Acute valvular regurgitation. Circulation. 2009;119(25):3232–41.CrossRefPubMedGoogle Scholar
  2. 2.
    Zoghbi WA, Enriquez-Sarano M, Foster E, Grayburn PA, Kraft CD, Levine RA, Nihoyannopoulos P, Otto CM, Quinones MA, Rakowski H, Stewart WJ, Waggoner A, Weissman NJ. Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. J Am Soc Echocardiogr. 2003;16(7):777–802.CrossRefPubMedGoogle Scholar
  3. 3.
    Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin 3rd JP, Guyton RA, O’Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt 3rd TM, Thomas JD. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(23):e521–643.CrossRefPubMedGoogle Scholar
  4. 4.
    Gelsomino S, Maessen JG, van der Veen F, Livi U, Renzulli A, Luca F, Carella R, Crudeli E, Rubino A, Rostagno C, Russo C, Borghetti V, Beghi C, De Bonis M, Gensini GF, Lorusso R. Emergency surgery for native mitral valve endocarditis: the impact of septic and cardiogenic shock. Ann Thorac Surg. 2012;93(5):1469–76.CrossRefPubMedGoogle Scholar
  5. 5.
    Olmos C, Vilacosta I, Fernandez C, Lopez J, Sarria C, Ferrera C, Revilla A, Silva J, Vivas D, Gonzalez I, San Roman JA. Contemporary epidemiology and prognosis of septic shock in infective endocarditis. Eur Heart J. 2013;34(26):1999–2006.CrossRefPubMedGoogle Scholar
  6. 6.
    Kiefer T, Park L, Tribouilloy C, Cortes C, Casillo R, Chu V, Delahaye F, Durante-Mangoni E, Edathodu J, Falces C, Logar M, Miro JM, Naber C, Tripodi MF, Murdoch DR, Moreillon P, Utili R, Wang A. Association between valvular surgery and mortality among patients with infective endocarditis complicated by heart failure. JAMA. 2011;306(20):2239–47.CrossRefPubMedGoogle Scholar
  7. 7.
    Habib G, Badano L, Tribouilloy C, Vilacosta I, Zamorano JL, Galderisi M, Voigt JU, Sicari R, Cosyns B, Fox K, Aakhus S. Recommendations for the practice of echocardiography in infective endocarditis. Eur J Echocardiogr. 2010;11(2):202–19.CrossRefPubMedGoogle Scholar
  8. 8.
    Lancellotti P, Tribouilloy C, Hagendorff A, Popescu BA, Edvardsen T, Pierard LA, Badano L, Zamorano JL. Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging. 2013;14(7):611–44.CrossRefPubMedGoogle Scholar
  9. 9.
    Siciliano RF, Gualandro DM, Mueller C, Seguro LF, Goldstein PG, Strabelli TM, Arias V, Accorsi TA, Grinberg M, Mansur AJ, De Oliveira Jr MT. Incremental value of B-type natriuretic peptide for early risk prediction of infective endocarditis. Int J Infect Dis. 2014;29:120–4.CrossRefPubMedGoogle Scholar
  10. 10.
    Fernandez-Hidalgo N, Almirante B, Tornos P, Gonzalez-Alujas MT, Planes AM, Larrosa MN, Sambola A, Igual A, Pahissa A. Prognosis of left-sided infective endocarditis in patients transferred to a tertiary-care hospital--prospective analysis of referral bias and influence of inadequate antimicrobial treatment. Clin Microbiol Infect. 2011;17(5):769–75.CrossRefPubMedGoogle Scholar
  11. 11.
    Hoen B, Alla F, Selton-Suty C, Beguinot I, Bouvet A, Briancon S, Casalta JP, Danchin N, Delahaye F, Etienne J, Le Moing V, Leport C, Mainardi JL, Ruimy R, Vandenesch F. Changing profile of infective endocarditis: results of a 1-year survey in France. JAMA. 2002;288(1):75–81.CrossRefPubMedGoogle Scholar
  12. 12.
    Sy RW, Kritharides L. Health care exposure and age in infective endocarditis: results of a contemporary population-based profile of 1536 patients in Australia. Eur Heart J. 2010;31(15):1890–7.CrossRefPubMedGoogle Scholar
  13. 13.
    Selton-Suty C, Celard M, Le Moing V, Doco-Lecompte T, Chirouze C, Iung B, Strady C, Revest M, Vandenesch F, Bouvet A, Delahaye F, Alla F, Duval X, Hoen B. Preeminence of Staphylococcus aureus in infective endocarditis: a 1-year population-based survey. Clin Infect Dis. 2012;54(9):1230–9.CrossRefPubMedGoogle Scholar
  14. 14.
    Tornos P, Iung B, Permanyer-Miralda G, Baron G, Delahaye F, Gohlke-Barwolf C, Butchart EG, Ravaud P, Vahanian A. Infective endocarditis in Europe: lessons from the Euro heart survey. Heart. 2005;91(5):571–5.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Thuny F, Di Salvo G, Belliard O, Avierinos JF, Pergola V, Rosenberg V, Casalta JP, Gouvernet J, Derumeaux G, Iarussi D, Ambrosi P, Calabro R, Riberi A, Collart F, Metras D, Lepidi H, Raoult D, Harle JR, Weiller PJ, Cohen A, Habib G. Risk of embolism and death in infective endocarditis: prognostic value of echocardiography: a prospective multicenter study. Circulation. 2005;112(1):69–75.CrossRefPubMedGoogle Scholar
  16. 16.
    Heiro M, Helenius H, Hurme S, Savunen T, Metsarinne K, Engblom E, Nikoskelainen J, Kotilainen P. Long-term outcome of infective endocarditis: a study on patients surviving over one year after the initial episode treated in a Finnish teaching hospital during 25 years. BMC Infect Dis. 2008;8:49.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Galvez-Acebal J, Rodriguez-Bano J, Martinez-Marcos FJ, Reguera JM, Plata A, Ruiz J, Marquez M, Lomas JM, de la Torre-Lima J, Hidalgo-Tenorio C, de Alarcon A. Prognostic factors in left-sided endocarditis: results from the Andalusian multicenter cohort. BMC Infect Dis. 2010;10:17.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Nadji G, Rusinaru D, Remadi JP, Jeu A, Sorel C, Tribouilloy C. Heart failure in left-sided native valve infective endocarditis: characteristics, prognosis, and results of surgical treatment. Eur J Heart Fail. 2009;11(7):668–75.CrossRefPubMedGoogle Scholar
  19. 19.
    Hasbun R, Vikram HR, Barakat LA, Buenconsejo J, Quagliarello VJ. Complicated left-sided native valve endocarditis in adults: risk classification for mortality. JAMA. 2003;289(15):1933–40.CrossRefPubMedGoogle Scholar
  20. 20.
    Sy RW, Chawantanpipat C, Richmond DR, Kritharides L. Development and validation of a time-dependent risk model for predicting mortality in infective endocarditis. Eur Heart J. 2011;32(16):2016–26.CrossRefPubMedGoogle Scholar
  21. 21.
    San Roman JA, Lopez J, Vilacosta I, Luaces M, Sarria C, Revilla A, Ronderos R, Stoermann W, Gomez I, Fernandez-Aviles F. Prognostic stratification of patients with left-sided endocarditis determined at admission. Am J Med. 2007;120(4):369 e1–7.CrossRefPubMedGoogle Scholar
  22. 22.
    Lopez J, Fernandez-Hidalgo N, Revilla A, Vilacosta I, Tornos P, Almirante B, Sevilla T, Gomez I, Pozo E, Sarria C, San Roman JA. Internal and external validation of a model to predict adverse outcomes in patients with left-sided infective endocarditis. Heart. 2011;97(14):1138–42.CrossRefPubMedGoogle Scholar
  23. 23.
    Delahaye F. Is early surgery beneficial in infective endocarditis? A systematic review. Arch Cardiovasc Dis. 2011;104(1):35–44.CrossRefPubMedGoogle Scholar
  24. 24.
    Bannay A, Hoen B, Duval X, Obadia JF, Selton-Suty C, Le Moing V, Tattevin P, Iung B, Delahaye F, Alla F. The impact of valve surgery on short- and long-term mortality in left-sided infective endocarditis: do differences in methodological approaches explain previous conflicting results? Eur Heart J. 2011;32(16):2003–15.CrossRefPubMedGoogle Scholar
  25. 25.
    Vikram HR, Buenconsejo J, Hasbun R, Quagliarello VJ. Impact of valve surgery on 6-month mortality in adults with complicated, left-sided native valve endocarditis: a propensity analysis. JAMA. 2003;290(24):3207–14.CrossRefPubMedGoogle Scholar
  26. 26.
    Habib G, Hoen B, Tornos P, Thuny F, Prendergast B, Vilacosta I, Moreillon P, de Jesus Antunes M, Thilen U, Lekakis J, Lengyel M, Muller L, Naber CK, Nihoyannopoulos P, Moritz A, Zamorano JL. Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009): the Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and the International Society of Chemotherapy (ISC) for Infection and Cancer. Eur Heart J. 2009;30(19):2369–413.CrossRefPubMedGoogle Scholar
  27. 27.
    Revilla A, Lopez J, Vilacosta I, Villacorta E, Rollan MJ, Echevarria JR, Carrascal Y, Di Stefano S, Fulquet E, Rodriguez E, Fiz L, San Roman JA. Clinical and prognostic profile of patients with infective endocarditis who need urgent surgery. Eur Heart J. 2007;28(1):65–71.CrossRefPubMedGoogle Scholar
  28. 28.
    Wang A, Pappas P, Anstrom KJ, Abrutyn E, Fowler Jr VG, Hoen B, Miro JM, Corey GR, Olaison L, Stafford JA, Mestres CA, Cabell CH. The use and effect of surgical therapy for prosthetic valve infective endocarditis: a propensity analysis of a multicenter, international cohort. Am Heart J. 2005;150(5):1086–91.CrossRefPubMedGoogle Scholar
  29. 29.
    Aksoy O, Sexton DJ, Wang A, Pappas PA, Kourany W, Chu V, Fowler Jr VG, Woods CW, Engemann JJ, Corey GR, Harding T, Cabell CH. Early surgery in patients with infective endocarditis: a propensity score analysis. Clin Infect Dis. 2007;44(3):364–72.CrossRefPubMedGoogle Scholar
  30. 30.
    Tleyjeh IM, Ghomrawi HM, Steckelberg JM, Hoskin TL, Mirzoyev Z, Anavekar NS, Enders F, Moustafa S, Mookadam F, Huskins WC, Wilson WR, Baddour LM. The impact of valve surgery on 6-month mortality in left-sided infective endocarditis. Circulation. 2007;115(13):1721–8.CrossRefPubMedGoogle Scholar
  31. 31.
    Sy RW, Bannon PG, Bayfield MS, Brown C, Kritharides L. Survivor treatment selection bias and outcomes research: a case study of surgery in infective endocarditis. Circ Cardiovasc Qual Outcomes. 2009;2(5):469–74.CrossRefPubMedGoogle Scholar
  32. 32.
    Lalani T, Cabell CH, Benjamin DK, Lasca O, Naber C, Fowler Jr VG, Corey GR, Chu VH, Fenely M, Pachirat O, Tan RS, Watkin R, Ionac A, Moreno A, Mestres CA, Casabe J, Chipigina N, Eisen DP, Spelman D, Delahaye F, Peterson G, Olaison L, Wang A. Analysis of the impact of early surgery on in-hospital mortality of native valve endocarditis: use of propensity score and instrumental variable methods to adjust for treatment-selection bias. Circulation. 2010;121(8):1005–13.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Galvez-Acebal J, Almendro-Delia M, Ruiz J, de Alarcon A, Martinez-Marcos FJ, Reguera JM, Ivanova-Georgieva R, Noureddine M, Plata A, Lomas JM, de la Torre-Lima J, Hidalgo-Tenorio C, Luque R, Rodriguez-Bano J. Influence of early surgical treatment on the prognosis of left-sided infective endocarditis: a multicenter cohort study. Mayo Clin Proc. 2014;89(10):1397–405.CrossRefPubMedGoogle Scholar
  34. 34.
    Martinez-Selles M, Munoz P, Arnaiz A, Moreno M, Galvez J, Rodriguez-Roda J, de Alarcon A, Garcia Cabrera E, Farinas MC, Miro JM, Montejo M, Moreno A, Ruiz-Morales J, Goenaga MA, Bouza E. Valve surgery in active infective endocarditis: a simple score to predict in-hospital prognosis. Int J Cardiol. 2014;175(1):133–7.CrossRefPubMedGoogle Scholar
  35. 35.
    Chu VH, Park LP, Athan E, Delahaye F, Freiberger T, Lamas C, Miro JM, Mudrick DW, Strahilevitz J, Tribouilloy C, Durante-Mangoni E, Pericas JM, Fernandez-Hidalgo N, Nacinovich F, Rizk H, Krajinovic V, Giannitsioti E, Hurley JP, Hannan MM, Wang A. Association between surgical indications, operative risk, and clinical outcome in infective endocarditis: a prospective study from the International Collaboration on Endocarditis. Circulation. 2015;131(2):131–40.CrossRefPubMedGoogle Scholar
  36. 36.
    Delahaye F, Rial MO, de Gevigney G, Ecochard R, Delaye J. A critical appraisal of the quality of the management of infective endocarditis. J Am Coll Cardiol. 1999;33(3):788–93.CrossRefPubMedGoogle Scholar
  37. 37.
    Gaca JG, Sheng S, Daneshmand MA, O’Brien S, Rankin JS, Brennan JM, Hughes GC, Glower DD, Gammie JS, Smith PK. Outcomes for endocarditis surgery in North America: a simplified risk scoring system. J Thorac Cardiovasc Surg. 2011;141(1):98–106 e1–2.CrossRefPubMedGoogle Scholar
  38. 38.
    Mirabel M, Sonneville R, Hajage D, Novy E, Tubach F, Vignon P, Perez P, Lavoue S, Kouatchet A, Pajot O, Mekontso-Dessap A, Tonnelier JM, Bollaert PE, Frat JP, Navellou JC, Hyvernat H, Hssain AA, Timsit JF, Megarbane B, Wolff M, Trouillet JL. Long-term outcomes and cardiac surgery in critically ill patients with infective endocarditis. Eur Heart J. 2014;35(18):1195–204.CrossRefPubMedGoogle Scholar
  39. 39.
    The Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC), European Association for Cardio-Thoracic Surgery (EACTS), Vahanian A, Alfieri O, Andreotti F, Antunes MJ, Baron-Esquivias G, Baumgartner H, Borger MA, Carrel TP, De Bonis M, Evangelista A, Falk V, Iung B, Lancellotti P, Pierard L, Price S, Schafers HJ, Schuler G, Stepinska J, Swedberg K, Takkenberg J, Von Oppell UO, Windecker S, Zamorano JL, Zembala M, Bax JJ, Ceconi C, Dean V, Deaton C, Fagard R, Funck-Brentano C, Hasdai D, Hoes A, Kirchhof P, Knuuti J, Kolh P, McDonagh T, Moulin C, Popescu BA, Reiner Z, Sechtem U, Sirnes PA, Tendera M, Torbicki A, Von Segesser L, Badano LP, Bunc M, Claeys MJ, Drinkovic N, Filippatos G, Habib G, Kappetein AP, Kassab R, Lip GY, Moat N, Nickenig G, Otto CM, Pepper J, Piazza N, Pieper PG, Rosenhek R, Shuka N, Schwammenthal E, Schwitter J, Mas PT, Trindade PT, Walther T. Guidelines on the management of valvular heart disease (version, 2012). Eur Heart J. 2012;33(19):2451–96.CrossRefGoogle Scholar
  40. 40.
    Shih CJ, Chu H, Chao PW, Lee YJ, Kuo SC, Li SY, Tarng DC, Yang CY, Yang WC, Ou SM, Chen YT. Long-term clinical outcome of major adverse cardiac events in survivors of infective endocarditis: a nationwide population-based study. Circulation. 2014;130(19):1684–91.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  1. 1.Department of Cardiology, Hôpital BichatDHU Fire and Paris Diderot UniversityParisFrance

Personalised recommendations