Beyond Standard Echocardiography in Infective Endocarditis
2018; Lippincott Williams & Wilkins; Volume: 11; Issue: 3 Linguagem: Inglês
10.1161/circimaging.118.007626
ISSN1942-0080
Autores Tópico(s)Streptococcal Infections and Treatments
ResumoHomeCirculation: Cardiovascular ImagingVol. 11, No. 3Beyond Standard Echocardiography in Infective Endocarditis Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBBeyond Standard Echocardiography in Infective EndocarditisComputed Tomography, 3-Dimensional Imaging, and Multi-Imaging Erwan Salaun, MD and Gilbert Habib, MD Erwan SalaunErwan Salaun From the Department of Cardiology, Assistance Publique Hopitaux de Marseille, La Timone Hospital, Marseille, France; and Aix Marseille Université, IRD, Assistance Publique Hopitaux de Marseille, MEPHI, IHU-Méditerranée Infection, France. and Gilbert HabibGilbert Habib From the Department of Cardiology, Assistance Publique Hopitaux de Marseille, La Timone Hospital, Marseille, France; and Aix Marseille Université, IRD, Assistance Publique Hopitaux de Marseille, MEPHI, IHU-Méditerranée Infection, France. Originally published19 Mar 2018https://doi.org/10.1161/CIRCIMAGING.118.007626Circulation: Cardiovascular Imaging. 2018;11:e007626Infective endocarditis (IE) is a complex disease, which associates cardiac localization and multiorgan complications, resulting in a challenging management.1 Prognosis depends on a prompt diagnosis and an adapted therapy that includes antibiotic therapy and early cardiac surgery when indicated.2 The diagnosis is made on the basis of multiple findings rather than a single definitive test result.3 In 1981, Von Reyn et al4 defined IE as suspected by clinical signs and persistent positive blood cultures and confirmed by direct evidence based on histology from surgery or autopsy or on bacteriology of valve vegetation or peripheral embolism. Since then, imaging of cardiac lesions appeared to be indispensable, and the Duke criteria by Durack et al5 introduced the endocardial involvement evidenced by echocardiography as a major diagnostic criterion. In 2000, the modified Duke criteria published by Li et al3 endorsed the widespread use of transesophageal echocardiography (TEE) in the field of IE diagnosis. Later, and in parallel with the improvement in computed tomography (CT) and nuclear imaging techniques, the use of both these modalities appeared useful and of particular interest for IE diagnosis.6,7See Article by Kim et alIn this issue of Circulation: Cardiovascular Imaging, Kim et al8 report their experience in the use of cardiac CT angiography (CTA) in patients with IE in the era of 3-dimensional images. Although recent guidelines or scientific statements recognized the role of multi-imaging in the diagnosis of left-sided IE,9–11 only a few publications have compared the value of TEE and cardiac CTA in the detection of IE-related cardiac lesion. Kim et al present an original work in which they attempted to answer the current question: Is the diagnostic performance of cardiac CTA better than TEE for detecting vegetation and IE-related cardiac complications?This article gives us the opportunity to review the evidence previously published on this topic and discuss the role of the imaging in the management of patients with IE.What Do We Know About Cardiac CT in IE?The use of cardiac CTA scan was first proposed to detect coronary artery disease in patients referred for conventional heart valve surgery.12 In the context of IE, this approach was rapidly recommended to rule out significant coronary artery disease when large aortic vegetation is present or when emergency surgery is necessary.In 2009, Feuchtner et al13 were the first to test the diagnosis capability of CTA in the detection of cardiac IE-related lesion. Among 37 patients with IE included in the study, 57 valves (aortic [n=28], mitral [n=28], tricuspid [n=1], and among them, only 6 prosthetic valves) were involved and thus included in the analysis. The intraobserver and interobserver agreement for diagnosis of IE and detection of vegetations, abscesses, fistulae, and mobility of vegetations by CTA were excellent (all κ ≥0.94). Compared with surgery findings, CTA had a good agreement (κ=0.78 per patient-based analysis and κ=0.93 per valve-based analysis) and similar to that of TEE (κ=0.78 per patient-based analysis and κ=0.97 per valve-based analysis). On the per-valve–based analysis, diagnostic accuracy compared with surgery was as follows: (1) for the detection of vegetations: sensitivity, 96%; specificity, 97%; positive predictive value, 96%; negative predictive value, 97%; (2) for the detection of abscesses/pseudoaneurysms: sensitivity, 100%; specificity, 100%; positive predictive value, 100%; negative predictive value, 100%; and (3) not significantly different from TEE.In 2010, Gahide et al14 studied 19 consecutive patients with active aortic IE requiring surgical intervention. Only 2 patients had prosthetic valves in this small cohort, the other valves affected were native valves (tricuspid aortic valve [n=15] and bicuspid aortic valve [n=2]). The sensitivity, specificity, positive predictive value, and negative predictive value of CTA in depicting pseudoaneurysms compared with surgical findings were 100%, 87.5%, 91.7%, and 100%, respectively. The sensitivity, specificity, positive predictive value, and negative predictive value of CTA in depicting vegetations were 71.4%, 100%, 100%, and 55.5%, respectively, but all 100% for depicting vegetations >1 cm.In 2012, Fagman et al15 focused on 27 consecutive patients with aortic prosthetic valve IE (mechanical valve [n=17] and bioprosthesis [n=10]). They found a good agreement between CTA and TEE for the detection of thickened wall (κ=0.83), a good agreement for the detection of dehiscence (κ=0.75) and abscess (κ=0.68), and a moderate agreement for the detection of vegetation (κ=0.55). Among the 16 patients who underwent cardiac surgery in this cohort, the agreement with all surgical findings (abscess, vegetation, and dehiscence) was (1) better for the TEE (κ=0.79) compared with that of the CTA (κ=0.66); and (2) the best and excellent (κ=0.88) with a combined imaging approach (both TEE and CTA). In a recent meta-analysis limited by the low volume of previously published data, Habets et al16 confirmed that this combined imaging strategy can improve the detection of cardiac IE-related lesions in patients with prosthetic valve IE, especially for the detection of periannular complications.Beyond the role in the IE diagnosis, the assessment by CTA had an impact on the therapeutic strategy. In a small cohort of 28 patients with prosthetic valve IE, CTA resulted in major diagnostic change in 6 patients (21%) and in therapeutic strategy in 7 (25%).17Recently, in a prospective cohort of 67 patients with aortic prosthetic valve IE assessed by both TEE and CTA, 58 had an indication for surgery based on the imaging findings.18 Among them, 19% had indication based exclusively on the TEE findings, 14% had indication based exclusively on CTA findings, and all others had indication based on the combined imaging. Surgery was finally performed in only 34 patients with indication from imaging examination, but in all cases, the imaging findings consistent with indication for surgery were confirmed at surgery.Results and Discussion of the Present StudyKim et al retrospectively analyzed data of 75 patients with definite IE who underwent echocardiography (transthoracic echocardiography and TEE) and CTA examination within 3 days at their institution from January 2008 to December 2015.Among the 75 patients included (mean age of 58.2 years and 71% of men), 34 (45%) had negative blood cultures (which is a high proportion),19 13 (17%) had a localization on a prosthetic valve (which is a low incidence),19 and 59 (79%) were referred to cardiac surgery during the index hospitalization (which is a high proportion).19 Concerning this study population, several questions require answers: (1) How many patients with IE were admitted during the study period? How many were excluded and why?; and (2) Was the CTA performed in all patients with IE in the study period? What was the reason for performing CTA?Concerning the detection of leaflet lesions, vegetations were detected in 73 patients (97%) by TEE, but CTA did not identify these vegetations in 19 patients (25%), mostly when the vegetations were small. Moreover, the agreement between the measurement of the vegetation length by TEE and CTA was moderate (r=0.59) when considering all vegetations and was low when considering only small vegetation <10 mm (r=0.19). The CTA assessment resulted in an almost systematic underestimation of the length compared with the TEE measurement (Figure 4 in the study by Kim et al).Concerning other leaflet lesions, TEE and CTA similarly detected valve aneurysm in 5 patients; however, valve perforation was detected in 26 patients by CTA and in 24 patients by TEE with a disagreement between both modalities in 4 patients. In these 4 patients, the surgical findings were still in favor of the TEE assessment. A false-positive diagnosis of intracardiac fistula by CTA was also confirmed by the surgical findings.Concerning the detection of perivalvular abscess: discrepancy between TEE and CTA assessment was found in 7 patients, with at each time a diagnosis of abscess by CTA but not found in TEE.Thus, Kim et al confirmed that CTA is helpful in the diagnosis of periannular complication but remains limited for vegetation assessment, which is a major limitation of CTA, owing to the major prognostic value of vegetation length. Moreover, the interpretation of flow by CTA should be performed with caution, even in an experienced team, because the rate of mistake is not insignificant (false-positive diagnosis of valve perforation [n=3] and intracardiac fistulae [n=1]).The small number of patients with valve prosthesis did not allow for performing comparative analysis of the CTA diagnosis accuracy between native and prosthesis-related valve IE in this cohort, whereas the expert consensus is that the CTA is mainly useful in the context of suspected periannular complication in patients with prosthetic valve. Since 2008 and the first inclusion in the present study, the use of 3-dimensional imaging grows in the field of valve heart disease, and the image technique has improved over time. However, although the pictorial interest of the 3-dimensional imaging (both TEE and CTA) is showed in some cases of IE (Figures 1 and 2 in the study by Kim et al), the incremental value in the diagnosis accuracy remains unproved.20Present and Future of Imaging in IEThe objective of imaging in patients with suspected IE is both to detect cardiac lesions and extracardiac complications or metastatic infection.The detection of the cardiac lesion is the key of IE diagnosis and a major diagnostic criterion11; the aim of the cardiac imaging analysis is 3-fold (Figure):Hemodynamic analysis corresponds to the need to assess the hemodynamic valve injury (regurgitation or obstruction) and its consequences on the cardiac function. It requires the use of both echocardiographic modalities: transthoracic echocardiography and TEE. Valve dysfunction resulting in symptoms of heart failure remains a major indication of early surgery.11,21Anatomic analysis corresponds to the detection of leaflet lesions (vegetations, perforation, and aneurysm) and periannular injury (abscess, pseudoaneurysm, and intracardiac fistulae). Transthoracic echocardiography may be of interest in few cases in this setting: (1) native left-sided valve IE with excellent echogenicity; (2) tricuspid valve IE; and (3) detection of anterior aortic abscess, especially in prosthetic valve IE. In all others cases, TEE is the gold standard, especially for the detection of vegetation and the measurement of its length, which have a major impact on the risk of embolism and the indication of early surgery.11,21 CTA is helpful to complete the periannular assessment (diagnosis and extension assessment) and plan the intervention and is an alternate solution when TEE is limited by echogenicity or prosthetic-related artifact.Functional analysis is the novelty in IE diagnosis and continuously developed during recent years. The 18F-fluorodeoxyglucose positron emission tomography (PET)/CT is the main technique used to detect inflammation related to infection, and the additional diagnostic value is important in patients with suspected prosthetic IE by reclassifying most possible IE cases into a more conclusive group (definite or rejected). Alternative techniques are (1) hybrid PET/CT scanner combined to CTA, thus combining the high sensitivity of PET/CT to detect inflammation with the high spatial resolution of CTA to define structural damage; or (2) radiolabeled white blood cell single-photon emission/CT that may be more specific than 18F-fluorodeoxyglucose PET/CT in some cases, such as the early postsurgical period.Imaging of extracardiac complication or metastatic infection is helpful in diagnosing IE by detection of minor diagnostic criteria but also mainly for the prognostic assessment. The detection of cerebral complication (embolism, hemorrhage, and abscess) by cerebral imaging should be performed in all patients with left-sided IE, even when neurological signs are not present.10 Magnetic resonance imaging has higher sensitivity to detect neurological and musculoskeletal complications or associated lesions than CT but remains less available for systematic screening in clinical practice routine. CT is of interest for the detection of intra-abdominal and vascular lesions or metastatic locations of the infection, as vascular mycotic aneurysm. Nuclear imaging (18F-fluorodeoxyglucose PET/CT) is highly sensitive for (1) the detection of peripheral embolism and metastatic infection in whole body (except in of brain location); (2) the diagnosis of occult lesion predisposing to IE (neoplastic lesions); and (3) the detection of alternative infectious or noninfectious diagnosis in rejected IE.The use of optimal imaging screening strategy depends on the availability and expertise in each technique. Two options to complete comprehensive echocardiography assessment (transthoracic echocardiography and TEE) are relevant in practical routine: (1) Specific protocol of CT acquisitions, which includes contrast agent infusion and uses a first ECG-gating acquisition for the cardiac assessment followed by a second acquisition covering the thorax, abdomen, pelvis, and cerebral regions. Nuclear imaging can complete the assessment if necessary, especially in prosthetic suspected IE; (2) Protocol of PET/CTA, which combines cardiac (anatomic and functional) assessment and detection of extracardiac complication or associated lesion. In this second scenario, cerebral magnetic resonance imaging is preferably performed as first cerebral imaging.To date, the interest of nuclear imaging in the determination of IE prognosis and the management of the antibiotic treatment remains unknown but could be of an important challenge in the future.A multispecialty heart valve team, the endocarditis team, was defined recently to embrace the complexity of the IE disease and the need for a collaborative approach.11 The development of the multi-imaging approach in the IE should lead to develop the imaging team as an essential component of the endocarditis team.Download figureDownload PowerPointFigure. Imaging modalities in infective endocarditis: strengths and weaknesses of each technique. CT indicates computed tomography; CTA, computed tomographic angiography; PET, positron emission tomography; TEE, transesophageal echocardiography; and TTE, transthoracic echocardiography.DisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Correspondence to Gilbert Habib, MD, Department of Cardiology, Hôpital La Timone, Blvd Jean-Moulin, 13005 Marseille, France. E-mail [email protected]References1. Cahill TJ, Baddour LM, Habib G, Hoen B, Salaun E, Pettersson GB, Schäfers HJ, Prendergast BD. Challenges in infective endocarditis.J Am Coll Cardiol. 2017; 69:325–344. doi: 10.1016/j.jacc.2016.10.066.CrossrefMedlineGoogle Scholar2. Habib G, Salaun E, Hubert S. Infective endocarditis: adeadly disease if diagnosed too late.J Am Soc Echocardiogr. 2016; 29:323–324. doi: 10.1016/j.echo.2016.02.010.CrossrefMedlineGoogle Scholar3. Li JS, Sexton DJ, Mick N, Nettles R, Fowler VG, Ryan T, Bashore T, Corey GR. 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Muratori M, Fusini L, Mancini M, Tamborini G, Ghulam Ali S, Gripari P, Doldi M, Frappampina A, Teruzzi G, Pontone G, Montorsi P and Pepi M (2022) The Role of Multimodality Imaging in Left-Sided Prosthetic Valve Dysfunction, Journal of Cardiovascular Development and Disease, 10.3390/jcdd9010012, 9:1, (12) March 2018Vol 11, Issue 3 Advertisement Article InformationMetrics © 2018 American Heart Association, Inc.https://doi.org/10.1161/CIRCIMAGING.118.007626PMID: 29555840 Originally publishedMarch 19, 2018 Keywordsendocarditistomographyblood cultureEditorialsPDF download Advertisement SubjectsComputerized Tomography (CT)EchocardiographyImaging
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