Is a Negative Transesophageal Echocardiogram Enough to Stop Treatment?

Abstract

SESSION TITLE: Cardiothoracic Surgery SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Infective Endocarditis (IE) is one of the most life threatening diseases. Echocardiography is a key tool used in diagnosing IE. There are times however when clinical suspicion outweighs diagnostic tests. CASE PRESENTATION: 35-year-old female presented with fever, joint pains, vomiting and a rash. Patient's medical history is significant for a bicuspid aortic valve and an ascending aortic aneurysm with a graft repair. Blood pressure was 93/66 and other vitals were within normal limits. Her physical exam was significant for generalized pustules (palms, soles, face), 2x2 cm ulcerated lesion on the tip of the 3rd right digit, and asymmetric joint tenderness. Cardiovascular exam was significant for Grade II Aortic, Crescendo murmur. Initial labs showed white blood cells count of 20.1 K/uL, Creatinine 2.11 mg/dL, CRP 275 mg/L, ESR 67 MM/HR. Blood cultures were positive for Staphylococcus Aureus. A transesophageal echocardiogram (TEE) showed a bicuspid aortic valve, and no evidence of valvular vegetation. Despite the lack of evidence on TEE, patient treated with Nafcillin for 6 weeks. She was discharged and over the next few weeks she followed up with her primary care doctor. A repeat echocardiogram in 6 weeks did not reveal any vegetations. DISCUSSION: TEE is recommended in patients with high clinical suspicion of IE and a negative or nondiagnostic TTE (transthoracic echocardiogram). The sensitivity of TEE for vegetation is approximately 96 percent for native valves and 92 percent for prosthetic valves, and the specificity for both is approximately 90 percent. Therefore the question arises whether we should continue treatment for IE if TEE is negative? As in this case, clinical suspicion of IE may persist after a negative TEE. Potential sources of false-negative TEE studies include vegetation’s that are smaller than the limits of resolution, previous embolization of vegetation, or inadequate views to detect small abscesses. Accurate differentiation between true vegetation’s and other IE-related changes, such as ruptured chordae, is frequently difficult. It is also important to emphasize that there are blind spots with TEE. CONCLUSIONS: When clinical suspicion of IE is high and the TEE results are negative, a repeat TEE study is warranted within 7 to 10 days, which may demonstrate previously undetected vegetations or abscesses. Even if a TEE is negative, treatment is warranted if clinical suspicion is high. Reference #1: Habib G, Lancellotti P, Antunes MJ, et al. 2015 ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2015;36:3075. Reference #2: Shively BK, Gurule FT, Roldan CA, Leggett JH, Schiller NB. Diagnostic value of transesophageal compared with transthoracic echocardiography in infective endocarditis. J Am Coll Cardiol. 1991;18:391-397. DISCLOSURE: The following authors have nothing to disclose: Mouzamjha Faroqui, Amal Shariff No Product/Research Disclosure Information