European Society of Cardiology-Proposed Diagnostic Echocardiographic Algorithm in Elective Patients with Clinical Suspicion of Infective Endocarditis: Diagnostic Yield and Prognostic Implications in Clinical Practice

Abstract

Background:Echocardiography plays a central role in diagnosing infective endocarditis (IE). Accordingly, the European Society of Cardiology (ESC) has proposed a diagnostic echocardiographic algorithm. However, new studies are still needed to evaluate the degree of implementation of these guidelines in clinical practice and their consequences on incidence and prognosis of IE.Aim:This study aims to investigate the diagnostic yield of the ESC proposed echocardiographic algorithm in patients with suspected IE. We also examined the association among IE diagnosis and clinical outcomes.Methods:Retrospective analysis of a series of patients undergoing the ESC algorithm for clinical suspicion of IE at our institution.Results:Between 2009 and 2013, 323 cases were managed by a multidisciplinary team for clinical suspicion of IE. Following ESC algorithm, 26 (8%) patients were diagnosed with IE and 297 (92%) had IE excluded. In 92% of patients with a good-quality negative transthoracic echocardiography (TTE) and low level of clinical suspicion, the first TTE was considered sufficient to rule out IE. During a mean follow-up of 2.3 ± 1.4 years, patients who had a final diagnosis of IE showed similar mortality (P = 0.2) and rates of combined endpoint (all-cause death, stroke/transient ischemic attack, advanced atrioventricular block, and heart failure) compared to patients without echocardiographic diagnosis of IE (P = 0.5). Only 1% of the patients who had IE excluded experienced IE in the following 3 months, none of them in the subgroup of patients, in which a first negative TTE was considered sufficient to rule out IE.Conclusions:In spite of the current ESC recommendation TTE is used as part of a routine fever screen. Consequently, only a minority of patients had a final echocardiographic diagnosis of IE. Although in patients with low clinical suspicion a first negative TTE is sufficient to rule out IE, the incidence of clinical events is similar regardless the final diagnosis of IE.

Normal values of the mitral-aortic intervalvular fibrosa thickness: A multimodality study

“…In our study, CT thickness was significantly lower than the echographic one, as a result of the higher CT spatial resolution. Multimodality imaging and a diagnostic algorithm have been already underlined by current guidelines,[262728] and other studies comparing multislice CT and TEE have never assessed this topic.…”

Pulmonary Regurgitation- Is the Future Percutaneous or Surgical?

“…In some cases, a positive blood culture in a clinically well patient can lead to 6 weeks of intravenous antibiotic treatment and firm diagnosis, whereas in other situations absence of surgical re-intervention can negate a firm clinical and laboratory diagnosis previously made. The fact that manuscripts still appear regularly with new guidelines and criteria for endocarditis should caution us particularly when reviewing large retrospective cohort studies ( 22 , 23 ). There is slowly growing evidence that the bovine jugular graft, used in the surgically placed Contegra and percutaneously placed Melody valve (both Medtronic Inc., Minneapolis, MN) have an intrinsic proclivity to infection ( 24 , 25 ).…”

Submitral Aneurysm Secondary to Infective Endocarditis: Review of Literature and Case Report

“…The sensitivity of Trans-esophageal Echocardiography (TEE) ranges between 85%-98%. In a study by Barbieri et al, a good quality TTE was found sufficient for diagnosis in 80% of cases with low level of clinical suspicion [28].…”

“…The use TEE is necessary in cases where TTE is positive/non diagnostic, suspected complications (perforation, abscesses and fistula) or presence of intra-cardiac device leads [28,29]. ACC/AHA valvular heart guidelines recommended use of cardiac CT analysis when the anatomy is unclear following echocardiography [24].…”