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Vol. 69. Issue 4.
Pages 442-445 (April 2016)
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Vol. 69. Issue 4.
Pages 442-445 (April 2016)
Scientific letter
DOI: 10.1016/j.rec.2015.12.007
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Multidetector Computed Tomography Usefulness in Infective Endocarditis
Utilidad de la tomografía computarizada con multidetectores en la endocarditis infecciosa
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Susana del Prado Díaza, Elena Refoyo Salicioa, Silvia Cayetana Valbuena-Lopeza, María Fernández-Velilla Peñab, Ulises Ramírez-Valdirisc, Gabriela Guzmán-Martíneza,
Corresponding author
gabrielaguzman.ny@hotmail.com

Corresponding author:
a Servicio de Cardiología, Hospital Universitario La Paz, Madrid, Spain
b Servicio de Radiodiagnóstico, Hospital Universitario La Paz, Madrid, Spain
c Servicio de Cirugía Cardiaca, Hospital Universitario La Paz, IdiPAZ, Madrid, Spain
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Table. Clinical Characteristics, Type of Endocarditis, Presence of Vegetation, Complications, and Coronary Anatomy
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To the Editor,

Infectious endocarditis (IE) still carries high morbidity and mortality. Currently, transesophageal echocardiography (TEE) is the reference imaging technique for the diagnosis and assessment of IE and its complications, but a series of noteworthy results have been published with multidetector computed tomography (MDCT) for presurgical assessment of IE.1–3 The new European Guidelines4 reinforce the role of MDCT both in suspected IE and in confirmed cases for assessment of complications with an extension of the major diagnostic criteria to include paravalvular lesions in MDCT. The European Society of Cardiology5 recommends preoperative assessment of coronary artery disease prior to surgery in selected patients; however, in the context of IE, invasive coronary angiography is associated with a nonnegligible risk of embolism.

We conducted a prospective study with the objective of assessing the utility of MDCT in IE. The study included 27 consecutive patients who met the diagnostic criteria for possible IE (41%) or definite IE (59%) according to the modified Duke criteria.4 A 64-detector device (thickness/cut increment 0.6/0.3mm, electrocardiogram-gated, field of view extended to the upper abdomen) was used with 80mL of intravenous contrast (350mg/mL, 5.5mL/s).

The results were compared with the findings from TEE and surgery in patients who underwent an intervention (Table). Five of the patients (18.5%) had device-associated IE (3 lead-associated and 2 central-catheter–associated) and 22 had valve-associated disease (57% associated with the native valve, 29% with a bioprosthesis, and 14% with mechanical valves).

Table.

Clinical Characteristics, Type of Endocarditis, Presence of Vegetation, Complications, and Coronary Anatomy

Patient  Sex, age, y  Probability of IE  Heart disease/underlying condition  Vegetation observed in TEE  Vegetation observed in MDCT  Complication diagnosed in TEE  Complication diagnosed in MDCT  Coronary arteries in MDCT  Extracardiac findings in MDCT 
F, 74  Possible  Mechanical mitral and aortic valve prostheses  No  No  Periaortic abscess
Suspected fistula 
Pseudoaneurysm
Fistula ruled out 
No lesions  Mycotic aneurysm in superior mesenteric artery 
M, 81  Possible  No  No  No  No  No  Two-vessel disease  Mural thrombus in ascending aorta 
M, 62  Definite  No  Yes
(native aortic) 
No  No  No  Unassessable
Intense calcification 
Embolization in spleen and psoas 
M, 76  Definite  Biological aortic valve prosthesis+ACBS  Yes
(aortic biological) 
Yes  MAJ abscess  No  Single-vessel disease
Patent bypass 
 
M, 41  Definite  No
Intravenous drug user 
Yes
(native tricuspid) 
No  No  No  No lesions  Pulmonary infarction 
F, 82  Possible  Biological aortic valve prosthesis+ACBS  Yes
(native mitral) 
No  No  No  Unassessable
Intense calcification 
 
M, 65  Definite  ACBS  Yes
(native aortic) 
Yes  No  Perforated leaflet  Three-vessel disease
Patent bypass 
Bilateral pleural effusion 
M, 59  Definite  Mechanical aortic valve prosthesis  Yes
(mechanical aortic) 
No  No  No  No lesions  Pleural effusion 
F, 80  Possible  ICD-CRT  Yes
(lead) 
No  No  No  Unassessable
Intense calcification 
 
10  M, 30  Possible  ICD  Yes
(lead) 
Yes  No  No  No lesions   
11  F, 66  Definite  Mechanical aortic valve prosthesis and pacemaker  Yes
(lead) 
No  No  No  No lesions   
12  M, 68  Definite  No  Yes
(native mitral and aortic) 
Yes  Perforated aortic leaflet
Mitral chord rupture 
Mitral chord rupture  No lesions  Splenic infarction
Pleural effusion 
13  M, 48  Possible  Aortic prosthetic tube  No  No  No  Assessment aortic tube  No synchronization  Periaortic hematoma 
14  F, 51  Possible  Central catheter  Yes
(catheter) 
Yes  No  No  Not assessable due to contrast failure  Subclavian vein thrombosis 
15  M, 84  Possible  Central catheter  Yes
(catheter) 
No  No  No  Three-vessel disease  Pulmonary consolidation
Jugular thrombosis 
16  M, 60  Definite  No  Yes
(native mitral) 
Yes  No  No  Right coronary and circumflex artery not assessable  Splenic infarction 
17  F, 57  Definite  Obstructive hypertrophic cardiomyopathy  Yes
(native mitral) 
Yes  MAJ abscess  MAJ abscess  No lesions   
18  M, 70  Definite  Biological aortic valve prosthesis  Yes
(aortic biological and native mitral) 
Yes  MAJ abscess
Prosthesis removal 
MAJ abscess
Prosthesis removal 
No lesions  Aneurysm of ascending aorta
Pleural effusion 
19  M, 76  Definite  Biological aortic valve prosthesis+ACBS  Yes (biological aortic)  Yes  MAJ abscess  MAJ abscess  LMCA disease+3 vessels
Patent bypass 
Splenic infarction
Pleural effusion 
20  F, 79  Definite  Biological aortic valve prosthesis  Yes
(MAJ) 
Yes  MAJ abscess  MAJ abscess  No lesions   
21  M, 32  Definite  Subaortic ventricular septal defect  Yes
(native aortic) 
Yes  No  No  No lesions  Splenic infarction 
22  M, 60  Definite  No  Yes
(native mitral) 
No  MAJ thickening  No  No lesions
 
Splenic infarction 
23  F, 23  Definite  Tetralogy of Fallot.
Right ventricle to pulmonary artery conduit 
Yes
(biological pulmonary) 
Yes  No  No  No lesions
Assessment right ventricle-pulmonary artery conduit 
Pulmonary thromboembolism 
24  M, 39  Possible  Bicuspid aortic valve  Yes
(native aortic) 
Yes  No  No  No lesions  Paraseptal emphysema 
25  M, 78  Definite  Biological aortic valve prosthesis  Yes
(native mitral) 
Yes  No  No  No lesions  Pleural effusion 
26  M, 81  Definite  Biological aortic valve prosthesis  No  No  Periaortic abscess  Periaortic abscess that infiltrates MAJ and encompasses LMCA, LADA, and CxA  LADA not assessable due to calcification
Remaining arteries without lesions 
Splenic infarction Pleural effusion 
27  M, 59  Definite  Mechanical aortic valve prosthesis  Yes
(aortic root) 
Yes  Periaortic abscess  Pseudoaneurysm in the sinus of Valsalva  No lesions   

ACBS, aortocoronary bypass surgery; CRT, cardiac resynchronization therapy; CxA, circumflex artery; ICD, implantable cardioverter device; IE, infectious endocarditis; F, female; LADA, left anterior descending artery; LMCA, left main coronary artery; M, male; MAJ, mitral-aortic junction; MDCT, multidetector computed tomography; TEE, transesophageal echocardiography.

Of note among the MDCT findings was the following:

  • -

    Suspected aortic fistula to the pulmonary trunk was ruled out and 2 suspected periaortic abscesses were appropriately assessed. These turned out to be pseudoaneurysms (Figure), in all cases associated with mechanical aortic valve prosthesis.

    Figure.

    Mechanical aortic-valve-prosthesis–associated endocarditis with pseudoaneurysm of the aortic root. Multidetector computed tomography identified a pseudoaneurysm in the right sinus of Valsalva (yellow arrow) in the coronal (A), sagittal (B), and axial (C) plane, and in the 3-dimensional reconstruction (D), along with a large vegetation affixed to the proximal ascending aorta (*). The vegetation was observed in transesophageal echocardiography (E), but the pseudoaneurysm was not detected. These findings were confirmed during surgery (F). LA, left atrium; LV, left ventricle; VP, mechanical aortic valve prosthesis.

    (0.42MB).
  • -

    Supracoronary prosthetic graft was assessed and a large hematoma was appropriately characterized in the graft region, without leaks or endocardial complications; a graft from the right ventricle to the pulmonary artery was assessed, with exact determination of the diameter of the ascending aorta in a patient who finally required implantation of a valve tube.

  • -

    Four of the 6 abscesses of the mitral-aortic junction were diagnosed with TEE and confirmed by surgery. One of these abscesses, which was an extensive lesion, could not be evaluated by echocardiography. Tomography was able to adequately define the limits of the abscess, which extended to the aortopulmonary window and which encompassed the coronary artery origin.

  • -

    In 77% of the patients, the native coronary arteries or the bypass were assessed.

  • -

    In all patients who had undergone a repeat procedure, the distance from the apex of the right ventricle or bypass to the sternum was determined.

  • -

    In 70% of the patients, extracardiac findings were reported. This is particularly important as these are minor criteria for peripheral arterial embolic events (26%), pulmonary infarction (7.4%), and mycotic aneurysms (3.7%).

  • -

    Of the 17 vegetations detected in TEE, 12 were valve-associated (both native and prosthetic) in the MDCT and an additional 3 device-associated vegetations were detected. The thread-like and hypermobile vegetations were those not detected.

The use of MDCT in IE, reinforced in the new guidelines,4 has not yet been assessed in Spain. In the present study, based on an extensive series, we would highlight several conclusions:

  • -

    In valvular IE, MDCT is key for visualizing the aortic wall, which is usually incompletely assessed with echocardiography. This structure is often affected by fistulas, pseudoaneurysms, and abscesses. The greatest advantage is apparent in IE associated with mechanical aortic valve prosthesis, in which complications are frequently present. Assessment with TEE can be particularly complicated given the presence of acoustic shadows.

  • -

    In addition, the technique allows assessment of the coronary artery and estimation of the distance from the right ventricular apex or coronary bypass to the sternum in patients with prior surgery and is also useful in right-sided IE for diagnosis of pulmonary embolism.

  • -

    However, in our experience, the information provided by MDCT is less relevant both for assessment of vegetations (mainly thread-like ones) and for device-associated IE, given that in the latter case, local complications are not usually present and major surgery is not required, and so assessment of coronary anatomy is not necessary.

Currently, with the development of a range of different imaging modalities, it is the responsibility of the cardiologist to be aware of the advantages of each technique to achieve the highest diagnostic accuracy. We believe that MDCT undoubtedly complements TEE in the management of IE.

References
[1]
G.M. Feuchtner, P. Stolzmann, W. Dichtl, T. Schertler, J. Bonatti, H. Scheffel, et al.
Multislice computed tomography in infective endocarditis: comparison with transesophageal echocardiography and intraoperative findings.
J Am Coll Cardiol., 53 (2009), pp. 436-444
[2]
E. Fagman, S. Perrotta, O. Bech-Hanssen, A. Flinck, C. Lamm, L. Olaison, et al.
ECG-gated computed tomography: a new role for patients with suspected aortic prosthetic valve endocarditis.
Eur Radiol., 22 (2012), pp. 2407-2414
[3]
D.W. Entrikin, P. Gupta, N.D. Kon, J.J. Carr.
Imaging of infective endocarditis with cardiac CT angiography.
J Cardiovasc Comput Tomogr., 6 (2012), pp. 399-405
[4]
G. Habib, P. Lancellotti, M.J. Antunes, M.G. Bongiorni, J.P. Casalta, F. Del Zotti, et al.
The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology.
[5]
A. Vahanian, O. Alfieri, F. Andreotti, M.J. Antunes, G. Barón-Esquivias, H. Baumgartner, et al.
The Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery.
Eur Heart J., 33 (2012), pp. 2451-2496
Copyright © 2016. Sociedad Española de Cardiología
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