An Approach to Improve the Negative Predictive Value and Clinical Utility of Transthoracic Echocardiography in Suspected Native Valve Infective Endocarditis

Abstract

Background In patients with suspected native valve infective endocarditis (IE), current guidelines recommend an initial transthoracic echocardiogram (TTE) followed by a transesophageal echocardiogram (TEE) if clinical suspicion remains. The guidelines do not account for quality of the initial TTE or other findings that may alter the study’s diagnostic characteristics. This may lead to unnecessary TEE procedures where the initial TTE was sufficient to rule out vegetation. Methods Patients with suspected native valve endocarditis that underwent a TTE followed by a TEE within 7 days between 1/1/2007 and 2/28/2014 were included. A negative TTE for vegetation was defined by either the standard approach (at least possible vegetation seen on TTE), or by applying a set of strict negative criteria incorporating other findings on TTE. Using TEE as the gold standard for presence of vegetation, the diagnostic performance of the two TTE approaches were compared. Results In total, 790 TTE/TEE pairs were identified. With the standard approach, 671 of the TTEs were negative, compared to 107 negative studies using the strict negative approach. The sensitivity and negative predictive value (NPV) of TTE for detecting vegetation were substantially improved using the strict negative approach (sensitivity: 98% [95% C.I. 95–99%] vs. 39% [95% C.I. 31%–47%], NPV: 97% [95% C.I. 92–99%] vs. 86% [95% C.I. 83–88%]). Conclusions The ability for TTE to exclude vegetation in patients is excellent when strict criteria for a negative study are applied. In low to intermediate risk patients with a strict negative TTE, follow up TEE may be unnecessary.

An appraisal of clinical practice guidelines for the appropriate use of echocardiography for adult infective endocarditis—the timing and mode of assessment (TTE or TEE)

“…TTE has been proven to have a sufficient negative predictive value for NVE in patients with low to intermediate risk when strict negative criteria were applied [ 21 , 22 ]. For these low-risk patients stratified based on clinical judgment with negative TTE, evidence revealed and guidelines proposed that TEE was not necessary [ 10 – 14 , 16 , 17 , 23 – 25 ].…”

An appraisal of clinical practice guidelines for the appropriate use of echocardiography for adult infective endocarditis—the timing and mode of assessment (TTE or TEE)

“…In addition, there are also other guidelines, like JCS 2017, which recommended TTE for the evaluation of valve dysfunction and hemodynamics based on its value as well as its feature of non-invasiveness and repeatability [16]. Actually, with the technological progress of echocardiography, TTE was proved to have a su cient negative predictive value of NVE for in-patients with low to intermediate risk when strict negative criteria are applied [22,23]. For these low risk patients strati ed based on clinical judgment with negative TTE, although few recommendations was made, guidelines proposed in the context or in the algorithm that a TEE was not required [10-14, 16, 17, 24], and this have been veri ed by the recently published Meta-analyses [25,26].…”

A Clinical Practice Guideline Appraisal for Appropriate Use of Echocardiography in Adult Infective Endocarditis—When to and by Which Mode to Perform an Echo?

“…In addition, there are other guidelines like JCS 2017 recommended TTE based on its value in evaluation of valve dysfunction and hemodynamics, also in its feature of noninvasive and repeatable [16]. Actually, with the technological progress of echocardiography, TTE was proved to have a su cient negative predictive value of native valve endocarditis (NVE) in patients with low to intermediate risk when strict negative criteria are applied [22,23]. And for these low risk patients strati ed based on clinical judgment, although few recommendations had been formed, guidelines had addressed in the context or in the algorithm that a repeated TEE is not required [10-14, 16, 17, 24], which have been veri ed by recently published Meta-analyses [25,26].…”