The usefulness of cardiac CT in the diagnosis of perivalvular complications in patients with infective endocarditis

Abstract

Objectives The aim of the study was to compare the usefulness of cardiac CT to transthoracic (TTE) and transesophageal (TEE) echocardiography in the diagnosis of infective endocarditis (IE) and perivalvular complications using surgical inspection as the gold standard. Material and methods Fifty-three consecutive patients (42 men, mean age 58.3 ± 12.5) with IE requiring surgical procedures were enrolled in the study. All patients underwent preoperative TTE, TEE, and CT. The presence of vegetations, perivalvular abscess/pseudoaneurysm, leaflet perforation, inflammatory infiltration, and prosthesis dehiscence was assessed. Results We analyzed 71 affected valves (58 native, 13 prosthetic). Intraoperative assessment revealed 11 abscesses/pseudoaneurysms. Sensitivity and specificity of echocardiography (TTE + TEE) and CT were 63%, 90% and 81%, 90%, respectively. The combination of CT and echocardiography allowed diagnosing all abscesses/pseudoaneurysms. Inflammatory infiltration was found intraoperatively in 15 patients. Sensitivity and specificity of TEE and CT were 53%, 94% and 46%, 100%, respectively. Intraoperative assessment revealed leaflet perforation in 16 patients. Sensitivity and specificity of TEE and CT were 75%, 79% and 43%, 89%. The sensitivity of the combination of TTE + TEE + CT was 81%. Perivalvular leakage was found in eight patients with a prosthetic valve. Sensitivity and specificity of echocardiography and CT were 100%, 100% and 88%, 100%, respectively. TEE showed higher sensitivity (97%) than CT (89%) in the diagnosis of vegetations. Conclusions The combination of TTE, TEE, and CT increased the sensitivity for the detection of valvular and perivalvular complications of IE. Key Points • CT is a useful modality in the diagnosis of IE and its local complications in addition to echocardiography. • For the detection of abscesses and pseudoaneurysms, CT is superior to echocardiography. Combining these two modalities can increase the sensitivity of diagnosing abscess/pseudoaneurysm up to 100%. • Adding CT to TEE increases the sensitivity for detection of inflammatory infiltrate. CT is not superior to echocardiography in diagnosing vegetations, valvular leaflet perforations, and perivalvular leaks, but it can be a useful tool when echocardiography is indeterminate.

Current Challenges in the Management of Infective Endocarditis

“…This tool shows good anatomical correlation, especially when diagnosing a perivalvular abscess of the aortomitral intervalvular fibrous body and other structures surrounding the aortic root, thus overcoming the limitations of TOE ( 75 – 77 ). Recent data support cardiac CT as an adjuvant exploration technique when a better depiction of valvular complications is needed or when echocardiography proves to be insufficient in both native ( 77 ) and prosthetic valve endocarditis ( 78 – 80 ). Furthermore, cardiac CT is frequently used to preoperatively assess the presence of coronary artery disease in aortic endocarditis where performing a coronary angiography carries a prohibitive high risk of the dislodgment of vegetations ( 74 ).…”

Higher incidence of perivalvular abscess determines perioperative clinical outcome in patients undergoing surgery for prosthetic valve endocarditis

“…PET-CT increased the sensitivity and specificity of the modified Duke criteria from 70 to 95%, reducing the number of patients with "possible IE "from 56 to 32% [22,23]. A combination of TTE, TEE and CT can increase the sensitivity for the detection of valvular and perivalvular complications in IE [11]. Therefore, early detection of perivalvular lesions by using CT imaging should be considered in suspected IE as implemented in the recent ESC guidelines for the management of IE [9].…”

“…Perivalvular infection is of a greater concern in PVE than NVE and occurs in 56-100% of PVE patients [1,4,10]. Previous studies suggested, that perivalvular infection worsens the prognosis, the perioperative mortality and the risk for reinfection or relapse of endocarditis [11,12]. The extension of the infection beyond the valve annulus leads to technically more demanding operations, requiring radical debridement and reconstruction [10].…”

Right-Sided Infective Endocarditis

“…Most of the studies show that central catheters are a risk factor for bacteremia and endocarditis [6,7,10]; nevertheless, Farrington et al did not find an increase of endocarditis in patients with central catheters in comparison with patients with arteriovenous fistulas [22].…”

“…The combination of echocardiography and CCT to diagnose abscess/pseudoaneurysm reaches 100% sensitivity. In pulmonary/right-sided endocarditis, CT may reveal concomitant pulmonary disease, including abscesses and infarcts [5,10].…”