Differentiating Mobile Masses on Transcatheter Aortic Valve: Thrombi or Vegetations?

A RARE CASE OF ENTEROCOCCUS FAECALIS BIOPROSTHETIC AORTIC VALVE ABSCESS

Diagnosing Endocarditis: Get the Picture?!

MIGHTY MITIS

CASE REPORT: BIOPROSTHETIC VALVE ENDOCARDITIS CAUSING NON-ST-ELEVATION MYOCARDIAL INFARCTION

BackgroundMethicillin-resistant Staphylococcus aureus (MRSA) infective endocarditis (IE) is associated with high morbidity and mortality. Management commonly includes six-weeks of antibiotics and surgical intervention, if the patient has complications. Current guidelines recommend obtaining an echocardiogram. Transesophageal echocardiogram (TEE) is preferred over transthoracic echocardiogram (TTE). We wanted to evaluate the role of a TEE in changing management of MRSA IE.MethodsA retrospective cohort of patients with MRSA IE was analyzed between January 2013 and July 2017 at a tertiary care facility in East Tennessee. Patients with prosthetic valves or cardiac devices were excluded. Demographic, echocardiographic, antibiotic, blood culture, mortality, and intravenous drug use data were collected (Figure 1).ResultsSeventy-eight patients met the inclusion criteria. TTE was performed on 73 patients while five patients proceeded directly to TEE. Of the 73 patients that had a TTE, 33 (45.2%) detected the presence of vegetation and 40 (54.8%) did not. Of the 33 patients with a positive TTE, 15 subsequently underwent TEE, confirming IE. Out of the 40 patients with a negative TTE, 34 underwent TEE, of which 22 (64.7%) showed a vegetation. (Figure 2). A total of ten patients (12.8%) from the study underwent surgery. Of these ten, three (30%) had a positive TTE only, with no subsequent TEE. Five (50%) had both a positive TTE and TEE, and two (20%) had a negative TTE but positive TEE.ConclusionTransthoracic echocardiogram was adequate to visualize vegetations in 45.2% of patients. Completing a TEE increased the sensitivity of visualizing a vegetation, but management was most often not altered. Only two patients (5%) with a negative TTE, but positive TEE proceeded to surgery because of the findings. This causes us to question whether a subsequent TEE needs to be pursued when a TTE is negative in the setting of definite or possible IE by the modified Duke criteria. Even if a vegetation is seen on TEE the patient would most likely receive the same treatment, 6 weeks of intravenous antibiotics, as if no vegetation was seen. Forgoing a TEE reduces risk to the patient of undergoing a procedure, and reduces costs to the healthcare system.DisclosuresAll authors: No reported disclosures.

BACKGROUND: Transesophageal echocardiography (TEE) is often recommended to exclude infective endocarditis (IE) in patients presenting with bacteremia despite a negative transthoracic echocardiogram (TTE). Previous studies showing inadequate sensitivity of TTE for native valve endocarditis are dated, and do not reflect modern advances in ultrasound image optimization technology. We hypothesized that with current generation echocardiography technology, a TTE absent mobile echo targets and without significant valvular abnormalities would have sufficient negative predictive value to exclude IE. METHODS: The Duke Echocardiographic Database was queried from 1/1/2007 [[Unable to Display Character: –]] 2/28/2014 for TTEs performed within 7 days prior to a TEE ordered for bacteremia/endocarditis. The dominant imaging platform used for both TTE and TEE during this era was the Philips IE33, with frequent use of fundamental frequencies to enhance spatial resolution beyond that of harmonic imaging alone. TTE studies identified as having poor sound transmission were excluded. A normal TTE was defined by the demonstration of normal cardiac anatomy, at most trivial valvular regurgitation, and absence of valvular stenosis, mobile/oscillating echo targets on valves, and hardware including catheters. The demonstration of an oscillating target on TEE along with clinical criteria based on chart review defined IE. RESULTS: A total of 974 unique patients had a TTE followed by a TEE within a week. IE was suggested in 209 of these patients by TEE. Among 107 patients meeting the a priori normal criteria on TTE, 3 patients had an abnormal TEE consistent with IE. These results correspond to a negative predictive value (NPV) of 97.2% (95% C.I. 91.4% - 99.3%) for a normal TTE to exclude IE. CONCLUSIONS: In this retrospective analysis from an academic medical center echocardiography laboratory, we demonstrated that an adequate quality TTE alone in a patient with a structurally normal heart without indwelling hardware has a high NPV for IE. Current TTE image optimization approaches may obviate the need to pursue TEE in patients after a recent preceding normal TTE.

Background: Infective endocarditis (IE) predisposes patients to severe morbidity and mortality. 2D transthoracic echocardiogram (TTE) is the preferred initial imaging modality of choice and frequently is followed by Transesophageal echocardiogram (TEE). Establishing the role of TTE and a TEE in ruling out IE can provide a framework for institutional changes leading to fewer invasive and costly TEE procedures. Methods: A retrospective chart review at the University of New Mexico Hospitals included patients diagnosed with IE for which echocardiography was performed. Demographic data, history of IV drug use, prior IE, physical exam findings, microbiology, echocardiographic findings, and post-imaging management changes were recorded. Results: We identified 101 patients with clinically suspected endocarditis for review. TTE was performed in all patients and TEE in 23 patients (23%). TTE results were positive for endocarditis in 11 patients (10.89%), negative in 83 patients (82.18%), and indeterminate in 6 patients (5.94%) and did not have surgical features. TEE was performed in 4 out of 11 patients with positive TTE. TEE did not change management in these cases. In the 6 cases of indeterminate TTE, treatment decisions could be made in 4 cases without a TEE. Two of the 101 patients had negative TTE but positive TEE. Both had MSSA bacteremia and a positive Duke score. TEE resulted in a longer antibiotic course. Treatment decisions could be made in 78% of patients with suspected infective endocarditis without a TEE. Conclusion: TEE has a small added value for the diagnosis of infective endocarditis, and treatment decisions can often be made in most patients without the use of TEE. In this study, TEE only changed care in 2% of patients with suspected IE without surgical features by increasing the duration of antibiotic treatment.

Information about a real patient is presented in stages (boldface type) to an expert clinician (Dr Adler), who responds to the information, sharing his reasoning with the reader (regular type). A discussion by the authors follows. Patient presentation: Mr H is a 61-year-old man with a medical history significant for hypertension, hyperlipidemia, and benign prostatic hyperplasia who was admitted to the medical service with a chief complaint of fevers. Eleven years before presentation, the patient underwent a prostate biopsy for a rapidly rising prostate-specific antigen, and there was no evidence for malignancy. The biopsy was complicated by septicemia, which was treated with antibiotics. Four months before admission, the patient presented to the urology clinic with worsening urinary retention, and the decision was made to proceed to transurethral resection of the prostate. A preoperative workup was significant only for a urine culture growing 1000 colonies of enterococcus, and no antimicrobial treatment was given. He underwent a technically successful transurethral resection of the prostate and was discharged home the next day after passing a voiding trial. Two days after being discharged, the patient had fevers to 102°F and was readmitted to the hospital. He was found to have an Enterococcus faecalis urinary tract infection and was treated with 1 day of intravenous cefepime before being discharged the next day on a 7-day course of amoxicillin–clavulanic acid. On the day after discharge, blood cultures that were drawn on admission grew E faecalis with the same susceptibility pattern cultured from the urine, but there was no alteration in the treatment plan. The patient’s fevers resolved. One month before admission, the patient presented to an outside emergency department with decreased exercise capacity, pleuritic back pain, and malaise. Computed tomography of the chest with contrast identified a right …

2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

Bioprosthetic Valve Thrombosis while on a Novel Oral Anticoagulant for Atrial Fibrillation

TRICUSPID VALVE INFECTIVE ENDOCARDITIS REQUIRING VALVE REPLACEMENT THREE TIMES IN AN IV DRUG USER

Background: Methicillin-resistant Staphylococcus aureus (MRSA) infective endocarditis (IE) is associated with high morbidity and mortality. Current IE guidelines recommend transesophageal echocardiogram (TEE) over transthoracic echocardiogram (TTE) to diagnose infective endocarditis. Management of IE in people who inject drugs (PWID) in many medical centers is mainly conservative with prolonged intravenous antibiotics. Cardiac valve replacement in these patients remains controversial, given the high risk of reinfection. This study’s purpose is to evaluate whether obtaining sequential TEE after TTE in PWID with MRSA native-valve IE changes the management plan in these patients.Methods: A retrospective cohort of patients who are 18 years of age or older and inject drugs with definite MRSA IE between 2013 and 2019 were studied. Their echocardiographic reports and overall management plans were reviewed.Results: One hundred and twenty-six patients met the inclusion criteria. TTE was performed in 121 patients and, of these patients, 69 (57%) had detectable valvular vegetations while 52 (43%) did not. Of the 52 patients with a negative TTE, 44 underwent TEE, 28 (53%) of which showed vegetation. A total of 18 (14%) patients underwent surgery. Of these, six (33%) patients had a positive TTE only, with no subsequent TEE. Ten (56%) patients had both a positive TTE and TEE, and two (11%) patients had a negative TTE but positive TEE.Conclusion: In this retrospective cohort, obtaining a sequential TEE after a TTE in PWID with proven MRSA native IE by modified Duke’s criteria changed the management plan in two patients. The decision to perform a TEE in these patients needs to be individualized. Larger studies are needed to better evaluate the role of TEE in this patient population.

325 Does Quality of Transthoracic Echocardiogram (TTE) Impact Predictive Value in Detecting Infective Endocarditis (IE)? A Single Centre Experience

ALL OVER THE PLACE: A CASE OF MULTIVALVULAR INFECTIVE ENDOCARDITIS

71-Year-Old Man With a New Heart Murmur