MioAtlas
G7: Infections and inflammation

Aortic infective endocarditis with perforation

Destructive bacterial or fungal infection of the native aortic valve characterized by the proliferation of infected vegetations on the ventricular aspect of aortic cusps, with tissue perforation, cusp laceration, or commissural detachment.

Open in 3D simulator

Definition

Destructive bacterial or fungal infection of the native aortic valve characterized by the proliferation of infected vegetations on the ventricular aspect of aortic cusps, with tissue perforation, cusp laceration, or commissural detachment, leading to acute or subacute aortic regurgitation of rapidly progressive course [C3] [G7-13].

Severity criteria

  • Mild (L): Effective regurgitant orifice area (EROA) < 0.10 cm² (< 10 mm²); Regurgitant volume (RV) < 30 mL/beat; Regurgitant fraction (RF) < 30 %; vena contracta width (VC) < 3.0 mm; Doppler pressure half-time (PHT) > 500 ms [V1] [V3].
  • Moderate (M): EROA 0.10–0.29 cm² (10–29 mm²); RV 30–59 mL/beat; RF 30–49 %; vena contracta (VC) 3.0–6.0 mm; PHT 200–500 ms [V1] [V3].
  • Severe (G): EROA ≥ 0.30 cm² (≥ 30 mm²); RV ≥ 60 mL/beat; RF ≥ 50 %; vena contracta (VC) > 6.0 mm; PHT < 200 ms (marked shortening in acute presentation due to rapid aortic-LV end-diastolic pressure equalization) [V1] [V3] [G1-03].
  • Vegetation size criterion: According to the ESC 2023 guideline [C3, Tabla 14], vegetation size > 10 mm confers high systemic embolic risk and > 30 mm requires urgent cardiac surgery.

Findings by layer

Hemodynamics

  • Left ventricular end-diastolic pressure (lvedp) and pulmonary capillary wedge pressure: Rapidly elevated in acute severe forms due to massive undamped filling into a normal-sized, normally compliant left ventricle [G1-03] [C3].
  • Systemic arterial pressure: In acute severe presentations, diastolic blood pressure drops but pulse pressure does not reach the extreme widening of the chronic form due to rapid diastolic pressure equilibration and low forward stroke volume [G1-03] [B4].
  • Forward cardiac output: Reduced in decompensated severe forms [G1-03].

Rhythm

  • Characteristic rhythm: Sinus tachycardia, adrenergic compensatory mechanism that shortens diastolic filling time and limits regurgitant volume [G1-03] [C3].

ECG

  • Sinus tachycardia with diffuse non-specific ST-segment and T-wave changes [C3].
  • Critical PR interval monitoring: De novo prolongation of the PR interval (prolonged PR interval / 1st degree AV block) provides early warning of perivalvular infectious extension toward the membranous septum and atrioventricular node [C3] [E2].

Heart sounds and murmurs

  • Diastolic murmur: Soft or blowing early decrescendo high-frequency murmur, audible at the mid left sternal border (3rd intercostal space / Erb point) with the patient in forced expiration [B1] [G7-13]. In acute severe forms, the murmur is short in duration and may be unimpressive due to rapid end-diastolic equalization between aorta and left ventricle [G1-03].
  • First heart sound (S1): Soft or muffled due to premature mitral valve closure caused by marked intraventricular end-diastolic hypertension [G1-03].
  • Systolic flow murmur: Accompanying functional mid-systolic ejection murmur in aortic area due to increased total forward stroke volume [B1].

Arterial pulse

  • In acute severe forms: Rapid pulse with brisk upstroke but not excessively wide amplitude (lacking the massive collapsing pulse of chronic Corrigan) due to premature mitral closure and restricted forward stroke volume [G1-03] [B4].

Jugular venous pulse

  • Usually normal in early stages; venous engorgement with prominent v wave if retrograde capillary hypertension triggers right ventricular failure [B3].

Maneuvers

  • Isometric handgrip: Increases systemic vascular resistance, intensifying the regurgitant diastolic murmur [B1].
  • Squatting: Increases venous return and systemic afterload, reinforcing murmur auscultation [B1].
  • Valsalva (strain phase): Decreases the murmur by reducing preload [B1].

Simulator severity grades

Simulator severity grades: Mild, Moderate, Severe
Baseline rhythm: Sinus Tachycardia

Also known as: Aortic infective endocarditis · Infective endocarditis of aortic valve · Aortic valve endocarditis · Native aortic valve endocarditis · Aortic endocarditis

Other pathologies in this group

Sources

  1. [B1] Bedside diagnosis of systolic murmurs . N Engl J Med (1988) . DOI: 10.1056/NEJM198806163182404 PubMed: 2897627
  2. [B3] The jugular venous pressure revisited . Cleve Clin J Med (2013) . DOI: 10.3949/ccjm.80a.13039 PubMed: 24085809
  3. [B4] The Carotid Pulse . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250154
  4. [C3] 2023 ESC Guidelines for the management of endocarditis . Eur Heart J (2023) . DOI: 10.1093/eurheartj/ehad193 PubMed: 37622656
  5. [E2] AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part III: intraventricular conduction disturbances: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology . Circulation (2009) . DOI: 10.1161/CIRCULATIONAHA.108.191095 PubMed: 19228822
  6. [G1-03] Acute aortic regurgitation . Circulation (2012) . DOI: 10.1161/CIRCULATIONAHA.112.113993 PubMed: 22927474
  7. [G7-13] Clinical presentation, etiology, and outcome of infective endocarditis in the 21st century: the International Collaboration on Endocarditis-Prospective Cohort Study . Arch Intern Med (2009) . DOI: 10.1001/archinternmed.2008.603 PubMed: 19273776
  8. [V1] 2025 ESC/EACTS Guidelines for the management of valvular heart disease . Eur Heart J (2025) . DOI: 10.1093/eurheartj/ehaf194 PubMed: 40878295
  9. [V3] Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation: A Report from the American Society of Echocardiography Developed in Collaboration with the Society for Cardiovascular Magnetic Resonance . J Am Soc Echocardiogr (2017) . DOI: 10.1016/j.echo.2017.01.007 PubMed: 28314623