“…23 Furthermore, when PET is used in this manner, we see the incremental benefit over the mDC in both NVE and PVE (AUC 0.883 NVE, AUC 0.877 PVE) with a prevalence of confirmed IE in 61% of our cohort at discharge (Figure 2). This is in comparison to similarly-sized series in the literature, with a sensitivity of 17.5%-57% in NVE, 9,12,19,20,24,25 and only 28.0% in EuroENDO. 8 Given the lack of typical TOE findings of significant valvular insufficiency and/or presence of vegetations in this cohort, it is unsurprising that fifty patients (72%) lacked a surgical indication and were managed medically.…”
Section: Discussionmentioning
confidence: 42%
“…Embolic phenomena were identified in 14 (20%) patients; splenic avidity and low volume mediastinal lymphadenopathy were not considered here, as while suggestive of infection, they are not specific for IE. 19 Semi-quantitative analysis using SUVs showed no clear diagnostic cut-off for SUV, SUV max or SUV mean , nor when these parameters were normalized to hepatic and mediastinal blood pool uptake (Table 4 ). Figure 3 Representative images of Endocarditis on PET-CT.…”
Section: Resultsmentioning
confidence: 99%
“…13 This relative delay to PET reflects real-world practice of a high-throughput nuclear medicine department in the United Kingdom's National Health Service, in comparison to other series' where PET was typically undertaken in \ 10 days. 8,12,13,19,23 with not all patients receiving broad-spectrum antibiotics for possible IE. 23 We would suggest the use of PET in IE requires involvement of an Endocarditis Team with high volume throughput.…”
Background
International guidance recognizes the shortcomings of the modified Duke Criteria (mDC) in diagnosing infective endocarditis (IE) when transoesophageal echocardiography (TOE) is equivocal. 18F-FDG PET/CT (PET) has proven benefit in prosthetic valve endocarditis (PVE), but is restricted to extracardiac manifestations in native disease (NVE). We investigated the incremental benefit of PET over the mDC in NVE.
Methods
Dual-center retrospective study (2010-2018) of patients undergoing myocardial suppression PET for NVE and PVE. Cases were classified by mDC pre- and post-PET, and evaluated against discharge diagnosis. Receiver Operating Characteristic (ROC) analysis and net reclassification index (NRI) assessed diagnostic performance. Valve standardized uptake value (SUV) was recorded.
Results
69/88 PET studies were evaluated across 668 patients. At discharge, 20/32 had confirmed NVE, 22/37 PVE, and 19/69 patients required surgery. PET accurately re-classified patients from possible, to definite or rejected (NRI: NVE 0.89; PVE 0.90), with significant incremental benefit in both NVE (AUC 0.883 vs 0.750) and PVE (0.877 vs 0.633). Sensitivity and specificity were 75% and 92% in NVE; 87% and 86% in PVE. Duration of antibiotics and C-reactive Protein level did not impact performance. No diagnostic SUV cut-off was identified.
Conclusion
PET improves diagnostic certainty when combined with mDC in NVE and PVE.
“…23 Furthermore, when PET is used in this manner, we see the incremental benefit over the mDC in both NVE and PVE (AUC 0.883 NVE, AUC 0.877 PVE) with a prevalence of confirmed IE in 61% of our cohort at discharge (Figure 2). This is in comparison to similarly-sized series in the literature, with a sensitivity of 17.5%-57% in NVE, 9,12,19,20,24,25 and only 28.0% in EuroENDO. 8 Given the lack of typical TOE findings of significant valvular insufficiency and/or presence of vegetations in this cohort, it is unsurprising that fifty patients (72%) lacked a surgical indication and were managed medically.…”
Section: Discussionmentioning
confidence: 42%
“…Embolic phenomena were identified in 14 (20%) patients; splenic avidity and low volume mediastinal lymphadenopathy were not considered here, as while suggestive of infection, they are not specific for IE. 19 Semi-quantitative analysis using SUVs showed no clear diagnostic cut-off for SUV, SUV max or SUV mean , nor when these parameters were normalized to hepatic and mediastinal blood pool uptake (Table 4 ). Figure 3 Representative images of Endocarditis on PET-CT.…”
Section: Resultsmentioning
confidence: 99%
“…13 This relative delay to PET reflects real-world practice of a high-throughput nuclear medicine department in the United Kingdom's National Health Service, in comparison to other series' where PET was typically undertaken in \ 10 days. 8,12,13,19,23 with not all patients receiving broad-spectrum antibiotics for possible IE. 23 We would suggest the use of PET in IE requires involvement of an Endocarditis Team with high volume throughput.…”
Background
International guidance recognizes the shortcomings of the modified Duke Criteria (mDC) in diagnosing infective endocarditis (IE) when transoesophageal echocardiography (TOE) is equivocal. 18F-FDG PET/CT (PET) has proven benefit in prosthetic valve endocarditis (PVE), but is restricted to extracardiac manifestations in native disease (NVE). We investigated the incremental benefit of PET over the mDC in NVE.
Methods
Dual-center retrospective study (2010-2018) of patients undergoing myocardial suppression PET for NVE and PVE. Cases were classified by mDC pre- and post-PET, and evaluated against discharge diagnosis. Receiver Operating Characteristic (ROC) analysis and net reclassification index (NRI) assessed diagnostic performance. Valve standardized uptake value (SUV) was recorded.
Results
69/88 PET studies were evaluated across 668 patients. At discharge, 20/32 had confirmed NVE, 22/37 PVE, and 19/69 patients required surgery. PET accurately re-classified patients from possible, to definite or rejected (NRI: NVE 0.89; PVE 0.90), with significant incremental benefit in both NVE (AUC 0.883 vs 0.750) and PVE (0.877 vs 0.633). Sensitivity and specificity were 75% and 92% in NVE; 87% and 86% in PVE. Duration of antibiotics and C-reactive Protein level did not impact performance. No diagnostic SUV cut-off was identified.
Conclusion
PET improves diagnostic certainty when combined with mDC in NVE and PVE.
“…The role of FDG-PET/CT in the diagnosis of native-valve endocarditis might be restricted to situations when there is a high suspicion but not enough evidence to fulfill Duke criteria. Additionally, FDG-PET/CT has diagnostic utility in detecting unexpected sources of primary infections and extracardiac complications of endocarditis, [48][49][50][51] with significant impact on patient management 52 (►Fig. 12).…”
Infective endocarditis is a relatively rare, but deadly infection, with an overall mortality of around 20% in most series. Clinical manifestations have evolved in response to significant epidemiological shifts in industrialized nations, with a move toward a nosocomial or health-care-related pattern, in older patients, with more episodes associated with prostheses and/or intravascular electronic devices and a predominance of staphylococcal and enterococcal etiology.Diagnosis is often challenging and is based on the conjunction of clinical, microbiological, and imaging information, with notable progress in recent years in the accuracy of echocardiographic data, coupled with the recent emergence of other useful imaging techniques such as cardiac computed tomography (CT) and nuclear medicine tools, particularly 18F-fluorodeoxyglucose positron emission/CT.The choice of an appropriate treatment for each specific case is complex, both in terms of the selection of the appropriate agent and doses and durations of therapy as well as the possibility of using combined bactericidal antibiotic regimens in the initial phase and finalizing treatment at home in patients with good evolution with outpatient oral or parenteral antimicrobial therapies programs. A relevant proportion of patients will also require valve surgery during the active phase of treatment, the timing of which is extremely difficult to define. For all the above, the management of infective endocarditis requires a close collaboration of multidisciplinary endocarditis teams.
“…18 F-FDG PET/CT has a sensitivity of 67–80%, specificity of 75%, positive predictive value of ∼90% and negative predictive value of ∼40% for the diagnosis of prosthetic valve endocarditis [44 ▪ –46], and a sensitivity and specificity of ∼85% for the diagnosis of infection in implanted cardiac devices [47]. In native valve IE, known for inducing a smaller white blood cell traffic [48], 18 F-FDG PET/CT alone showed a sensitivity within the range of 20–57% and a specificity approximating 100% [49 ▪ ,50].…”
Purpose of reviewThe incidence of infective endocarditis (IE) is increasing worldwide, resulting in a higher number of patients with IE being admitted to intensive care units (ICU). Nearly half of patients with IE develop a complication during their clinical course. However, few well conducted studies or reviews are devoted to critically ill IE patients. This review discusses the contemporary perioperative and intensive care literature.Recent findings IE epidemiology is changing towards elderly and frail patients. ICU patients are at risk of risk of developing IE because they are often in a pro-inflammatory state and many also have several indwelling catheters, which favors infection. Increased performance and recent advances in cardiac imaging allow for easier diagnosis of EI, but the applicability of these techniques to ICU patients is still relatively limited. New developments in antibiotic treatment and adjunctive therapies are explored further in this review.
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