Invective endocarditis is an inflammation of the inner lining of the heart, particularly the heart valves, resulting in an infection that usually caused by bacteria, but may also result from other pathogens (fungi).

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At the moment, there is a great variety of methods of diagnosis and treatment options of this disease in Israel – enhanced visualization capabilities, massive antibiotic therapy and surgical treatment (replacement heart valve).


Endocarditis leads to the formation of bacterial colonies on the heart valves, which may cause serious damage to cardiac function and systemic embolism associated with the spread of infection to various organs.


In the past, the main cause of this disease was rheumatic heart disease as a result of the treatment of streptococcal infections with antibiotics. But now the main causes associated with long life expectancy are operations on the heart valves (bacteria prosthetic valves, mechanical and biological), the installation of a pacemaker, or other causes, such as injecting drug use.


This disease is considered by our specialists as an acute and severe. In this situation, the majority of patients developed fever with rapid deterioration, which can lead to death. The disease can occur in subacute condition that develops slowly, has less severe clinical symptoms and generally causes less damage to the heart valves and embolism.


The mechanism and causes of endocarditis

The endothelium is the innermost layer, lining the heart, including cardiac valves. In normal endothelium is resistant to bacteria. But with significant damage to the endothelium the bacteria can begin intensive breeding, for example when they were entered on the endothelium through a blood clot that occurs for various reasons (aortic stenosis, mitral insufficiency, ventricular septal defect and other conditions of blood clots). This condition called bacterial thrombus endocarditis (NBTE).


The bacteria can be separated by the method of contact with the endothelium. Such as streptococci, staphylococci, Haemophilus influenzae, cardiobacteria, gram negative bacteria (HACEK) fall through the throat and upper respiratory tract. Enterococci come from the circulatory system of the genitourinary system. Bovis streptococcus (S. Bovis) falls from the gastrointestinal tract and associated with tumors and polyps of the colon.


Among the most common drug bacteria causing endocarditis are streptococcus, staphylococcus, which usually fall to the right side of the heart (tricuspid valve). Coxiella Burnetii bacterium also causes fever and endocarditis can result in chronic phase.


Patients with mechanical or biological artificial valve are at risk for endocarditis, especially during the first few months after surgery.


Symptoms of endocarditis, such as fever and heart murmur, in some cases, chills and sweating, heart failure (as a result of the participation of the valve), abscesses, fistulas, embolism, loss of weight and appetite, back pain, arthritis, enlarged spleen, neurological symptoms, confusion, weakness on one side, bleeding in the brain, seizures, Janeway syndrome , Roth spots, Osler’s nodes, anemia, hematuria (blood in the urine).


Diagnosis of endocarditis

The diagnosis of infective endocarditis is carried out in accordance with the criteria of Duke (Duke), approved by the Research Service of the University of endocarditis Duke, USA.


The main criteria:

1. Positive blood cultures as a result of several tests under certain conditions. There is a critical value for the bacteria that cause disease. For proper treatment and prevention should appreciate cultures taken at 24 hours from different parts of the vein.
2. Echocardiography is needed to determine the abscess, the mass of the heart or regurgitation of the valve.
3. Transthoracic echocardiography (through the chest wall) can demonstrate defeat only in some patients. Therefore, most often performed transesophageal echocardiography (transesophageal). TEE can determine endocarditis more than 90% of patients, and if not defined but suspected endocarditis, the study repeated throughout the week.


Minor criteria

1. Risk factors for endocarditis: previous cardiac problems (valve prosthesis, etc.) or a history of injecting drug use.
2. The body temperature of over 38 degrees.
3. Evidence of vascular lesions – large arterial embolism, myocardial infectious origin, aneurysm, cerebral hemorrhage, bleeding of the conjunctiva, Janeway syndrome.
4. Evidence of the involvement of the immune system – glomerulonephritis, renal dysfunction, rheumatoid factor, Osler nodes, Roth spots.
5. Microbiological evidence – positive blood culture, which does not meet the above criteria or serological evidence that there is an active infection associated with infective endocarditis.
6. Laboratory tests: increasing CRP, anemia, a large number of white blood cells in some cases (leukocytosis) antibody complexes in blood and low levels of the complement system, which can be seen in the accumulation of antibodies.
7. Hematuria (blood in the urine), in some cases it may be kidney embolism.


Treatment of endocarditis

To ensure effective treatment is necessary to destroy all the bacteria that cause the disease. Typically, this is achieved by taking a long course of antibiotics. In most cases, treatment may be intravenous, within a few weeks. During the third week of treatment may have an allergic reaction to the medication, so it is very important control of the attending physician, who will be able to appoint a suitable medication in a timely manner to prevent toxic levels.


Surgical treatment

In some cases our specialists may recommend surgery to avoid complications that can lead to serious injury or death.
The operation can be immediate (in severe and life-threatening situations, such as acute aortic regurgitation, pericardial injury) or planned (in situations that do not require rapid surgical intervention, but has to be held in the near future – for example, the presence of a fungal infection or exacerbation valve function). An exception to this may be situations neurological problems arising after infection (e.g., septic embolism, cerebral aneurysm), which may deteriorate after surgery.


The indications for surgery are as follows:
Heart failure due to valve dysfunction, results of operations which show a better prognosis for patients.


Partial displacement of the valve prosthesis as a result of the infection.


Inability to cure the infection (fungal infection associated with Brucella, for example), or resistance of some bacteria (Enterococcus, Gram-negative bacteria). As an indication for surgery in this context is a poor response to treatment aureus, in the case involving the aortic or mitral valve.


Staphylococcal infection (Staphylococcus aureus) in the valve prosthesis complications in the heart associated with a high mortality rate, and in this case may be indications for surgery.


Recurrence of endocarditis in prosthetic valve, despite optimal medical therapy.


Infection that spread to all the valves of the heart. The main symptoms – does not decrease the temperature, despite treatment with antibiotics, there is an arrhythmia(as a result of infection associated with the conduction system of the heart) or pericarditis.


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