Suggested modification of the recommendations for echocardiography in patients with clinical suspicion of infective endocarditis

Abstract

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Infective endocarditis (IE) is a serious condition that requires prompt diagnosis and treatment. Transthoracic echocardiography (TTE) is usually the initial imaging modality, however transoesophageal echocardiography (TOE) is often necessary because of its higher sensitivity for IE compared with TTE. Yet, TOE has an increased risk of complications. The European Society of Cardiology (ESC) has established guidelines for the management of IE with recommendations for the use of TOE in patients with clinical suspicion of IE. Purpose This project aims to evaluate the ESC recommendations for the use of TOE in patients with clinical suspicion of IE. The purpose of the study is further to examine whether the ESC recommendations for TOE among patients with clinical suspicion of IE result in an unnecessarily large number of negative TOE examinations. Methods All TOE examinations performed due to referrals of patients with clinical suspicion of IE between 1 May 2019 and 30 April 2020 at a university hospital in our city were analysed. The variables included for analysis were age; sex; cardiac comorbidities; prosthetic valves; blood culture results; results from TTE and TOE; number of TOEs during the inclusion period; Duke criteria. The TOE and TTE results were compared in relation to the ESC guidelines. Results In total 195 TOE examinations from 160 patients were included, of which 61 (31%) TOEs were positive for IE. All examinations were of patients with clinical suspicion of IE, of which 37 (19%) had negative TTE. Of the 37 patients with negative TTE, 13 had prosthetic valve or intracardiac device of which 5 had positive TOE. All the 24 (12%) examinations with negative TTE and no prosthetic valve or intracardiac device had negative TOE. Conclusions The ESC recommendations for TOE in patients with clinical suspicion of IE are probably broad enough not to miss patients with IE, but there might be an unnecessarily large number of patients that get referred for TOE with negative results. To avoid this, we propose a modification of the recommendations for TOE in patients with clinical suspicion of IE. Negative TTE examination with good image quality and no indications for TOE according to Fig 1, could result in avoiding unnecessary TOE examinations without jeopardizing the IE diagnosis. Abstract Figure. Fig 1