Echocardiography In Infective Endocarditis Research Articles

Three-dimensional Transesophageal Echocardiography in Infective Endocarditis: What Does It Add?

Abstract Infective endocarditis (IE) diagnosis is based on a clinical suspicion supported by consistent microbiological and instrumental data. Evidence of involvement of cardiac valves (native or prosthetic) or prosthetic intracardiac material is a major diagnostic criterion of IE. Transthoracic echocardiography (TTE) is the initial technique of choice for the diagnosis while transesophageal echocardiography (TEE) is recommended in patients with an inconclusive or negative TTE, in patients with high suspicion of IE, as well as in patients with a positive TTE, in order to document local complications. Repeating TTE and/or TEE should be considered during follow-up of uncomplicated IE, in order to detect new silent complications and monitor vegetation size. In the setting of IE, the role of three-dimensional (3D) TEE is increasing; in fact, this technique has also been shown to be useful for the diagnosis of IE and its complications as it allows to obtain infinite planes and volumetric reconstructions. In this review, we will describe the usefulness of 3D-TEE and its added value in the management of IE.

Echocardiography in Infective Endocarditis: A High Hit Rate at Te Whatu Ora Waitaha/Canterbury

Echocardiography in Infective Endocarditis: A High Hit Rate at Te Whatu Ora Waitaha/Canterbury

Echocardiography in Infective Endocarditis: A High Hit Rate at Te Whatu Ora – Waitaha Canterbury

To evaluate the utility of echocardiography in General Medicine (GM) patients referred with possible infective endocarditis at Christchurch Hospital. Over a 6-month period between 1 January and 30 June 2021, all General Medicine in-patients who underwent echocardiography for any indication were screened to find those with possible infective endocarditis as an indication. This study reviewed the result of each echocardiogram and followed each patient over a 12-month period to determine the rate of infective endocarditis as the primary outcome. Secondary outcomes were the microbiological characteristics of those with infective endocarditis and operative rates. Of 262 GM patients who underwent echocardiogram during the study period, 88 (34%) patients were referred with possible endocarditis. Nineteen of 88 (22%) patients had definite or presumed infective endocarditis as a discharge diagnosis, comprising 12 (14%) patients with definite infective endocarditis, six patients with high clinical suspicion and non-diagnostic imaging who were treated as presumed endocarditis, and one patient with negative imaging subsequently readmitted with subacute prosthetic valve endocarditis. Five patients required operative management. Most of the culture-positive endocarditis in this series (70%) were from Streptococcus species; one had Staphylococcus aureus endocarditis. Approximately one in three echocardiograms performed on General Medicine patients at Christchurch Hospital are for possible infective endocarditis. A significant proportion of these patients are subsequently diagnosed with infective endocarditis. Given the scarcity of echocardiography, a case could be made for increasing resources and research into clinical predictive factors, which could further improve diagnostic rates.

Echocardiography in Infective Endocarditis: An Update on its Usefulness: How, When, How Much and Where?

Echocardiography is the main imaging technique in the diagnosis of Infective Endocarditis (IE). In 85-90% of cases this diagnosis is based on some echocardiographic criteria. Transthoracic echocardiography is an inexpensive test, quickly accessible without side effects, which has become the initial imaging technique of choice in the diagnosis of IE, as well as in the assessment of complications and follow-up. Transesophageal echocardiography also plays an important role in IE, increasing the diagnostic accuracy to almost 90%, especially in complicated cases. The new technologies implemented in the last decade have improved the assessment of these patients. Among them, 3D echocardiography has proven to be useful in the localization of periprosthetic leaks, valve perforations, fistulae as well as in the extensions of aneurysms and abscesses. The increased availability of echographs and the reduction in their size have led to perform hand-held cardiac ultrasound not only by cardiologists, but also by intesivists, anesthesiologists and internists among other specialties. This review is intended to help the clinician to better understand the usefulness of echocardiographic technique in the IE assessment and to review its new roles with the evolution of technology.

A narrative review of echocardiography in infective endocarditis of the right heart.

Infective endocarditis (IE) is characterized by bacterial or fungal masses that form in the cardiac chambers and valves, and in severe cases invade the endocardium or intra-cardiac vessels. Right-sided IE accounts for 5% to 10% of cases, with a low mortality cited at 6%. A history of intravenous drug abuse (IVDU) is present in 90% of isolated right-sided IE cases, with normal intra-cardiac anatomy prior to infection in approximately 80%. Nevertheless, up to 50% of patients require early surgical intervention which is associated with significant peri-operative morbidity. Echocardiography is the gold standard for diagnosis with a sensitivity of 80% for the transthoracic modality and 95% for transesophageal studies; it provides important clinical information regarding the severity of infection and development of secondary complications. This includes identification of active infective vegetations, healed IE, prosthetic valve IE, and abscess formation and rupture. Prompt clinical, microbiologic, and imaging assessment of patients with suspected left or right-sided IE is of paramount importance and is reflected in the modified Duke criteria, the well-validated algorithm for accurate and timely diagnosis of IE. Data suggests the criteria sensitivity may be decreased in right-sided IE only, and thus, care must be taken to perform skilled and detailed echocardiographic assessments of the right heart in suspected cases. Herein we provide a review of IE of the right heart, with a focus on pathophysiology and its echocardiographic presentation and characteristics.

Diagnostic performance of cardiac computed tomography versus transesophageal echocardiography in infective endocarditis: A contemporary comparative meta-analysis

To compare the diagnostic accuracy of transesophageal echocardiography (TEE) and cardiac computed tomography (CCT) in diagnosing infective endocarditis (IE). TEE is a mainstay imaging modality for IE, while the use of CCT is becoming increasingly prevalent. Data directly comparing the diagnostic performance of these two imaging modalities for IE are limited. We conducted a systematic review and meta-analysis of published literature in Embase, PubMed and Cochrane databases through October 1, 2020 for studies comparing diagnostic performance of CCT and TEE for the diagnosis of IE in the same patient populations. A meta-analysis of diagnostic accuracy was performed using the bivariate model based on studies that used surgical pathology as a reference standard for defining endocarditis. From a total of 10 studies included in the meta-analysis, a total of 872 patients were evaluated. The pooled sensitivities and specificities of TEE for detecting vegetations were 96% and 83% respectively, whereas for CCT, they were 85% and 84%, respectively. In the prosthetic valve sub-group, the pooled sensitivities and specificities of TEE for detecting vegetations were 89% and 74% respectively, whereas for CCT, they were 78% and 94%, with CCT being more specific than TEE (p<0.05). The pooled sensitivities and specificities of TEE for detecting periannular complications were 70% and 96% respectively, whereas for CCT, they were 88% and 93%, respectively. CCT showed a trend (p=0.06) towards higher sensitivity than TEE for detection of periannular complications. The pooled sensitivities and specificities of TEE for detecting leaflet perforation were 79% and 93% respectively, whereas for CCT, they were 48% and 93% respectively, with TEE being more sensitive (p<0.05). The two modalities also showed comparable diagnostic performance for detecting fistulae, paravalvular leaks and prosthetic valve dehiscence. In a contemporary comparative meta-analysis, TEE and CCT demonstrated both good diagnostic accuracy for detecting valvular involvement and complications of IE. TEE performed better for detecting leaflet defects, whereas CCT performed better in cases of prosthetic valve involvement, and showed a trend towards improved detection of periannular complications. Appropriate, complementary use of both TEE and CCT in a multimodality imaging approach in clinical practice may achieve the highest diagnostic performance.

Infective endocarditis in children-pattern, diagnosis, management and short term outcome in Sudan

Introduction: Infective Endocarditis (IE) in children is relatively rare but causes significant morbidity and mortality when it occurs. The incidence of IE in children is increasing worldwide. Objective: To identify pattern, management and short outcome of IE in Sudanese children. Methods: Retrospective notes review of all the children from birth to 16 years old, diagnosed with IE at Ahmed Gasim Children’s hospital, Khartoum North, Sudan. During the 12 month period starting from January 2017. All children who fulfilled Dukes criteria for Definite or Possible IE were included in the study. Results: During the study period 6260 children were admitted to Ahmed Gasim Children’s hospital, 47 patients fulfilled Dukes criteria for IE; Three patients were labelled as Definite and 44 as Possible, The majority of the patients were overfive years old. Of the 47 patients enrolled in the study,34% had normal hearts and 66.0% were known to have structural cardiac disease; out of them, 17 patients (54.8%) were known to have Rheumatic heart disease (RHD) and 14 patients (45.2%) were known to have Congenital Heart Disease (CHD).The hospital mortality was 21.3%. Conclusion and Recommendation: IE in Sudanese children is not rare and is associated with high hospital mortality,the health professionals should have a high index of suspicion to diagnose IE echocardiography and blood culture should be done whenever the possibility of endocarditis is entertained. The children, parents and caregivers of children with structural heart disease should be educated about IE’spresentation and prevention.

Comparative Value of Cardiac CT and Transesophageal Echocardiography in Infective Endocarditis: A Systematic Review and Meta-Analysis.

To assess the comparative diagnostic accuracy of cardiac CT and transesophageal echocardiography (TEE) in the detection of valvular and perivalvular complications in infective endocarditis. PubMed and Embase databases were systematically searched until July 2019 for original articles published in English. Studies were included if (a) they used CT and/or TEE as an index test, (b) data were provided as infective endocarditis valvular complications (classified as abscess or pseudoaneurysm, vegetation, leaflet perforation, and paravalvular leakage), and (c) they used surgical findings as the reference standard. Eight studies fulfilled the inclusion criteria. The sensitivity was higher for CT than TEE for abscess or pseudoaneurysm detection, 78% (95% confidence interval [CI]: 70%, 85%) (112 of 142) versus 69% (95% CI: 62%, 76%) (94 of 135) (P = .052) and increased to 87% (95% CI: 78%, 93%) (70 of 79) when restricted to multiphase CT studies, the difference being significant (P = .04). The sensitivity was significantly higher for TEE than CT for vegetation detection, 94% (95% CI: 92%, 96%) (363 of 383) versus 64% (95% CI: 57%, 70%) (151 of 237) (P < .001) and leaflet perforation detection, 81% (95% CI: 71%, 88%) (74 of 91) versus 41% (95% CI: 25%, 59%) (14 of 35) (P = .02).The sensitivity for paravalvular leakage was 69% (95% CI: 58%, 79%) (56 of 80) versus 44% (95% CI: 30%, 59%) (21 of 48) for TEE and CT, respectively (P = .27). CT performs better than TEE in the detection of abscess or pseudoaneurysm whereas TEE gives superior results for vegetation detection, leaflet perforation, and paravalvular leakage.Supplemental material is available for this article.© RSNA, 2020.

Repeat transesophageal echocardiography in infective endocarditis: An analysis of contemporary utilization.

Current guidelines from the American Heart Association (AHA) recommend repeating transesophageal echocardiography (TEE) in three to five days if there is high suspicion of IE despite an initial TEE that was negative. This recommendation, however, is based on limited published data. This investigation attempts to identify specific factors that prompted repeat TEE and evaluate the yield of IE-related findings demonstrated by repeat TEE as compared to initial or prior TEE. A retrospective cohort who had at least one repeat TEE during an index hospitalization or initial course of antimicrobial therapy for IE between January 2014 and September 2018. We assessed the impact of repeat TEE on IE diagnosis and patient management and included a comparative analysis of patients with initial TEE only. Overall, 59 (44.7%) of 132IE patients underwent repeat TEE. In a comparative analysis that involved patients who had undergone an initial TEE only versus those who had repeat TEE, male gender (P=.029) and presence of a prosthetic valve or annuloplasty ring (P=.017) were significantly associated with repeat TEE. Importantly, 8 (17.4%) of repeat TEE were critical for IE diagnosis, 8 (17.4%) impacted antimicrobial management, and 11 (23.9%) supported cardiovascular surgical intervention. From a population-based cohort of incident IE cases, repeat TEE was more frequently (44.7%) done in patients with suspect or proven IE and associated complications than anticipated. Repeat TEE remains pivotal in a contemporary practice that involves critical aspects of IE diagnosis and management.

Morphological characterization of vegetation by real‐time three‐dimensional transesophageal echocardiography in infective endocarditis: Prognostic impact

Vegetation size is a prognostic predictor in infective endocarditis (IE) and guides surgical management. The aim of this study was to evaluate the accuracy of real-time 3-dimensional transesophageal echocardiography (RT3DTEE) compared to 2DTEE in the diagnosis and characterization of vegetation, as well as its potential clinical impact. Two hundred and three consecutive patients with IE were recruited (2009-2016) and retrospectively analyzed. Vegetation diameters and area from 68 patients were measured by 2DTEE and RT3DTEE at admission. The association between size and systemic embolisms was evaluated with logistic regression models. Differences in the discriminative power for the best dimensions' cutoff points were assessed by comparing the area under the ROC curves (AUC). Vegetation size and area were larger by RT3DTEE (P<0.001) than by 2DTEE, and RT3DTEE was especially relevant in the characterization of nonfiliform vegetation, Morphology was strongly associated with friability, being sessile vegetation less likely to embolize, compared to filiform and raceme-shaped ones (15.4% vs 46% vs 50%). Major diameter by RT3DTEE had better embolic predictive performance than 2DTEE (AUC 0.76 [0.57-0.89] vs 0.71 [0.53-0.86]; P=0.611). The best cutoff points associated with embolic events during the infection were 17mm for RT3DTEE and 15mm for 2DTEE. Based exclusively on vegetation size, the proportion of patients meeting a surgical indication according to current guidelines is higher using RT3DTEE. RT3DTEE allows a better characterization of IE vegetation than 2DTEE, what may have a clinical impact on surgical management and also prognostic due to a more accurate prediction of embolic risk.

Echocardiography in Infective Endocarditis: State of the Art.

In this review, we examine the central role of echocardiography in the diagnosis, prognosis, and management of infective endocarditis (IE). 2D transthoracic echocardiography (TTE) and transesophageal echocardiography TEE have complementary roles and are unequivocally the mainstay of diagnostic imaging in IE. The advent of 3D and multiplanar imaging have greatly enhanced the ability of the imager to evaluate cardiac structure and function. Technologic advances in 3D imaging allow for the reconstruction of realistic anatomic images that in turn have positively impacted IE-related surgical planning and intervention. CT and metabolic imaging appear to be emerging as promising ancillary diagnostic tools that could be deployed in select scenarios to circumvent some of the limitations of echocardiography. Our review summarizes the indispensable and central role of various echocardiographic modalities in the management of infective endocarditis. The complementary role of 2D TTE and TEE are discussed and areas where 3D TEE offers incremental value highlighted. An algorithm summarizing a contemporary approach to the workup of endocarditis is provided and major societal guidelines for timing of surgery are reviewed.

Is a Negative Transesophageal Echocardiogram Enough to Stop Treatment?

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

An audit of echocardiographic referrals for investigation of infective endocarditis at Middlemore Hospital - can we do better?

Background: The referral criteria for screening echocardiography in infective endocarditis (IE) are undefined. The positive predictive value in this scenario is low and overuse of “screening’ echocardiography is potentially costly to the health system. We reviewed the appropriateness of referrals for echocardiography in the investigation of IE and the cost involved. Methods: We retrospectively reviewed all echocardiography referrals for suspected IE at Middlemore Hospital in 2012. Strongly indicated referrals were defined as: treatment for IE, Staphylococcus aureus bacteraemia or candidaemia. Results: A total of 7658 echocardiograms were performed between Jan 2012 and Dec 2012. 232 echocardiograms were performed for suspected IE. 88 (37.9%) referrals were deemed indicated; 33 (38%) patients were treated for IE. For those not treated as IE, 51 (58%) had Staphylocuccus aureus bacteraemia and 4 (4.5%) had candidaemia. Vegetation was identified in 10 (4.3%) patients. The most common alternative diagnoses were sepsis without identified focus (13%), respiratory infection (13%) and septic arthritis (10%). At a cost of NZD215.37 per echocardiogram the excess cost of echocardiograms without strong indication was NZD31013.28. Conclusions: The majority of echocardiograms referrals for suspected IE at our centre did not have strong indication, potentially generating unwarranted costs to the healthcare system. Greater efforts are needed to improve the appropriate use of echocardiography for suspected IE.

Recommendations for the practice of echocardiography in infective endocarditis

Echocardiography plays a key role in the assessment of infective endocarditis (IE). It is useful for the diagnosis of endocarditis, the assessment of the severity of the disease, the prediction of short- and long-term prognosis, the prediction of embolic events, and the follow-up of patients under specific antibiotic therapy. Echocardiography is also useful for the diagnosis and management of the complications of IE, helping the physician in decision-making, particularly when a surgical therapy is considered. Finally, intraoperative echocardiography must be performed in IE to help the surgeon in the assessment and management of patients with IE during surgery. The current 'recommendations for the practice of echocardiography in infective endocarditis' aims to provide both an updated summary concerning the value and limitations of echocardiography in IE, and clear and simple recommendations for the optimal use of both transthoracic and transoesophageal echocardiography in IE.

Infective endocarditis at a hospital in Saudi Arabia: epidemiology, bacterial pathogens and outcome

BACKGROUND AND OBJECTIVE:Data on infective endocarditis prevalence, epidemiology and etiology from Saudi Arabia and the Gulf region are sparse. We undertook this study to describe the pattern and the causative agents of endocarditis at a hospital in Saudi Arabia.METHODS:We conducted a retrospective analysis of all reported endocarditis cases at the Dhahran Health Center from January 1995 to December 2008.RESULTS:Of the 83 cases of endocarditis, 54 (65%) were definite endocarditis and the remaining 29 (35%) were possible endocarditis based on the Duke criteria. Patients with definite endocarditis included 39 males and 15 females (ratio of 2.6:1) with a mean age (SD) of 59.7 (18.2) years. Of the definite endocarditis cases, native valve endocarditis occurred in 44 (81.5%) cases of and prosthetic valve endocarditis was observed in 10 (18.5%). The most commonly involved valves were mitral (n=24; 44.4%) and aortic (n=20; 39.2%). The most common organisms were S aureus (n=23; 42.6%), Enterococcus faecalis (n=12; 22.2%) and viridans streptococci (n=9; 16.7%). Surgical intervention was required in 17 (31.4%) cases and the in-hospital mortality rate was 29.4% (n=15). Of all the patients, 3 (5.5%) had embolic stroke as a complication.CONCLUSION:Native valve endocarditis is the predominant type of endocarditis. The patients were older adults and the most common organisms were S aureus, E faecalis and viridans streptococci.

Use of echocardiography in the diagnosis and management of infective endocarditis

The first use of echocardiography in infective endocarditis (IE) was described in 1973. Since then, echocardiography has emerged as a major tool for the diagnosis and management of this disease. In general, transthoracic echocardiography (TTE) is adequate for diagnosing IE in cases where cardiac structures-of-interest are well visualized. Specific situations where transesophageal echocardiography is preferred over TTE include the presence of a prosthetic device, suspected periannular complications, children with complex congenital cardiac lesions, selected patients with Staphylococcus aureus bacteremia, and certain pre-existing valvular abnormalities that make TTE interpretation problematic (eg, calcific aortic stenosis). Echocardiography is also useful for risk stratification. Evidence suggests that vegetation size can predict embolic complications, although the data are inconsistent. Careful clinical assessment is essential to the proper use of echocardiography in diagnosing IE, visualizing complications related to IE, and evaluating candidacy for surgical intervention.

Echocardiography in infective endocarditis: what is the best time and what is the best approach?

Echocardiography in infective endocarditis: what is the best time and what is the best approach?

ACC/AHA/ASE 2003 Guideline Update for the Clinical Application of Echocardiography: Summary Article: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to update the 1997 guidelines for the clinical application of echocardiography)

ACC/AHA/ASE 2003 Guideline Update for the Clinical Application of Echocardiography: Summary Article: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to update the 1997 guidelines for the clinical application of echocardiography)

Intracardiac echocardiography in the detection of pacemaker lead endocarditis

At times, infection of pacemaker leads can be difficult to confirm even with transesophageal echocardiography. We describe a patient with pacemaker lead infection where the transesophageal echocardiogram was nondiagnostic, and intracardiac echocardiography made the diagnosis by demonstrating the vegetation on the pacemaker lead. This illustrates a potential role for intracardiac echocardiography in infective endocarditis when transesophageal echocardiography is nondiagnostic. (J Am Soc Echocardiogr 2002;15:1027-8.)

The Role of Echocardiography in Infective Endocarditis

Infective endocarditis continues to be a significant diagnostic and therapeutic problem. During the last two decades, transthoracic echocardiography, and more recently, transesophageal echocardiography have been used in patients with the clinical syndrome of endocarditis to detect vegetations and assess the extent of valvular damage. Certain echocardiographic findings have important prognostic implications and can help determine the timing of surgical intervention. This paper will review the role of echocardiography in the evaluation and management of patients with infective endocarditis.