MioAtlas
G7: Infections and inflammation

Mitral infective endocarditis with perforation

Destructive bacterial or fungal infection of the mitral valve characterized by the presence of septic vegetations and tissue perforation or tearing of mitral leaflets.

Open in 3D simulator

Definition

Infection of the mitral valve endothelium caused by pathogenic microorganisms (predominantly Staphylococcus aureus, Streptococcus viridans, or Enterococcus) characterized by the formation of infected platelet-leukocyte vegetations on the atrial surface of leaflets, with tissue destruction (perforation, laceration, or chordal rupture) leading to acute or subacute regurgitant mitral regurgitation [C3] [G7-13].

Severity criteria

  • Mild (L): Effective regurgitant orifice area (EROA) < 0.20 cm² (< 20 mm²); Regurgitant volume (RV) < 30 mL/beat; Regurgitant fraction (RF) < 30 %; vena contracta width (VC) < 3 mm [V1] [V3].
  • Moderate (M): EROA 0.20–0.39 cm² (20–39 mm²); RV 30–59 mL/beat; RF 30–49 %; vena contracta (VC) 3.0–6.9 mm [V1] [V3].
  • Severe (G): EROA ≥ 0.40 cm² (≥ 40 mm²); RV ≥ 60 mL/beat; RF ≥ 50 %; vena contracta (VC) ≥ 7 mm [V1] [V3].
  • Vegetation size criterion: According to ESC 2023 [C3, Tabla 14], vegetation size > 10 mm confers high thromboembolic risk and > 30 mm constitutes an indication for urgent surgical intervention.

Findings by layer

Hemodynamics

  • Pulmonary capillary wedge pressure / mean left atrial pressure: Elevated in moderate and severe stages, with prominent pathological systolic v wave due to retrograde ejection into the left atrium [V3] [C3].
  • Effective forward cardiac output: Decreased in acute severe forms due to diversion of stroke volume into the left atrium [V3].
  • Left ventricular ejection fraction: Preserved or hyperdynamic (60–75%) in early compensated phase [V1] [V3].

Rhythm

  • Predominant rhythm: Sinus tachycardia as a reflex response to fever, endotoxemia, anemia, and volume overload [C3] [G7-13].
  • Alternative: Atrial fibrillation in cases with prior left atrial dilation or acute severe overload [C3].

ECG

  • Sinus tachycardia; possible signs of left atrial overload (P mitrale wave) in subacute presentations [E1].
  • Without primary PR interval abnormalities unless there is rare extension to the posterior fibrous trigone [C3].

Heart sounds and murmurs

  • Systolic murmur: Holosystolic mitral regurgitation murmur, high-pitched and blowing or harsh in the mitral area (apex) [B1] [G7-13].
    • Radiation to axilla if vegetation/destruction predominates in the anterior leaflet.
    • Radiation toward base/aortic area if perforation or posterior leaflet involvement predominates [B1].
  • Third heart sound (S3): Present in severe mitral regurgitation due to rapid and voluminous ventricular diastolic filling [B1] [V3].
  • First heart sound (S1): Decreased or muffled due to valve coaptation defect [B1].

Arterial pulse

  • In severe forms: Rapid-rising pulse (celer) with reduced amplitude (relative parvus) in case of forward output decline [B4].

Jugular venous pulse

  • Generally normal in early stages; increased v wave and systemic venous hypertension if retrograde pulmonary hypertension develops [B3].

Maneuvers

  • Isometric handgrip: Increases systemic vascular resistance (afterload), increasing regurgitation and murmur intensity [B1].
  • Squatting: Increases venous return and afterload, increasing the murmur [B1].
  • Valsalva (phase II strain): Decreases murmur intensity by reducing venous return and ventricular volume [B1].

Simulator severity grades

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

Also known as: Mitral infective endocarditis · Infective endocarditis of mitral valve · Mitral valve endocarditis · Native mitral valve endocarditis · Mitral 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. [E1] AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part V: electrocardiogram changes associated with cardiac chamber hypertrophy: 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.108.191097 PubMed: 19228820
  6. [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
  7. [V1] 2025 ESC/EACTS Guidelines for the management of valvular heart disease . Eur Heart J (2025) . DOI: 10.1093/eurheartj/ehaf194 PubMed: 40878295
  8. [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