Endocarditis pathophysiology

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Maliha Shakil, M.D. [2]


The pathogenesis of infective endocarditis includes valvular damage, altered and turbulent flow, bacteremia, and lack of blood supply to the valves. Damaged endothelium becomes a site for attachment of infectious agents in infectious endocarditis. Nonbacterial thrombotic endocarditis is related to hypercoagulable states such as pregnancy or systemic bacterial infection. The characteristic lesion of endocarditis is vegetation. Vegetations are composed of fibrin, inflammatory cells, platelets, and microorganisms.



Infective Endocarditis

  • The pathogenesis of infective endocarditis includes:
Pathogenic Factors Mechanism
Valvular Damage
  • Altered and turbulent flow
  • Catheters, electrodes, and other intracardiac devices
  • Solid particles from repeated intravenous injections
  • Chronic inflammation
Lack of blood supply to valves
  • Blunted immune response
  • Therapeutic drugs have difficulty reaching infected valves

Nonbacterial Thrombotic Endocarditis

  • The exact pathogenesis of nonbacterial thrombotic endocarditis is not completely understood.
  • Nonbacterial thrombotic endocarditis (NBTE), also called marantic endocarditis is most commonly found on previously undamaged valves.
  • The vegetations in nonbacterial thrombotic endocarditis are sterile and small.
  • The vegetations mostly aggregate at the edges of the valve or the cusps.
  • We can divide the pathogenesis pathway of nonbacterial endocarditis into to phase:
    • Initiating phase
      • Immune complexes:[1][2]
        • Circulating immune complexes and complement deposition can initiate the process.
        • The example for this initiating factor in libman sacks endocarditis in lupus patients.
      • Hypoxia:[3][4]
        • Some studies demonstrated that hypoxia may lead to tissue factor activation.
        • Higher tissue factor level has an association with higher rate of endocarditis.
        • Other studies implies that the rate of endocarditis is higher in smokers and patients with chronic lung disease and possibly hypoxia.
      • Hypercoagulability:[5][6]
        • There is an association between hypercoagulable state and clotting factor abnormalities with initiation of nonbacterial thrombotic endocarditis.
      • Carcinomatosis:[7]
        • The association between cancer and nonbacterial thrombotic endocarditis is well established.
        • In most of the cases of cancer related endocarditis we have abnormal activity of tissue factor.
        • Tissue factor may be secreted from promyelocytic leukaemia cells.
        • Tissue factor may be expressed on the surface of adenocarcinoma cells which leads to increased expression of tissue factor by endothelial cells.
    • Verrucae formation


Genes involved in the pathogenesis of infective endocarditis include:[8]

  • Interleukin-6 c.471+870G>A
  • Interleukin-1b c.315C>T
  • Selectin-E c.-19 GT

Genes involved in the pathogenesis of nonbacterial thrombotic endocarditis include:[9]

Associated Conditions

Conditions associated with endocarditis include:

Gross Pathology

On gross pathology, characteristic findings of endocarditis are:

Endocarditis Subtype Features on Gross Pathology
Infective Endocarditis
  • Left-sided valve involvement (mitral, aortic) more common generally
  • Right-sided valve involvement (pulmonic, tricuspid valve) more common in intravenous drug abusers
  • Valvular vegetations
  • Valvular destruction
Nonbacterial Thrombotic Endocarditis
  • Round non-destructive vegetations, usually at the line of closure

Microscopic Pathology

On microscopic histopathological, characteristic findings of endocarditis are:

  • Vegetation:
    • Vegetations are composed of fibrin, inflammatory cells, platelets, and microorganisms.[25]
Endocarditis Subtype Features on Histopathological Microscopic Analysis
Infective Endocarditis
  • Inflammatory infiltrate
  • Abundant neutrophils
  • Plasma cells may be present in subacute endocarditis
  • Microorganisms present
Nonbacterial Thrombotic Endocarditis
  • Vegetations without inflammation and microorganisms

Image courtesy of Professor Peter Anderson DVM Ph.D. and published with permission © PEIR, the University of Alabama at Birmingham, Department of Pathology


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