Review

Infective endocarditis: Beyond the usual tests

Nkemdilim Mgbojikwe, MD, Steven R. Jones, MD, Thorsten M. Leucker, MD, PhD and Daniel J. Brotman, MD
Cleveland Clinic Journal of Medicine August 2019, 86 (8) 559-567; DOI: https://doi.org/10.3949/ccjm.86a.18120

Article Figures & Data

Figures

  • Figure 1A
    Figure 1A

    Transesophageal echocardiography in a 73-year-old man with a bioprosthetic aortic valve who presented with 2 months of fevers, chills, and night sweats. He had several negative blood cultures and 2 negative transesophageal echocardiograms over 1 month. No mass, vegetation, paravalvular abscess, or significant valve dysfunction was noted.

  • Figure 1B
    Figure 1B

    Cardiac computed tomographic (CT) angiography with iodinated contrast, including 4D reconstruction, in the same patient, however, shows an 11-mm vegetation on the bioprosthetic aortic valve leaflets (arrow).

  • Figure 1C
    Figure 1C

    Fluorodeoxyglucose positron emission tomography (FDG-PET) in the same patient confirms the diagnosis, showing a 13-mm hypermetabolic focus on the prosthetic valve (arrow), yielding the diagnosis of infectious endocarditis.

  • Figure 2
    Figure 2

    Suggested algorithm for evaluating suspected infective endocarditis with negative or inconclusive results on echocardiography.

Tables

  • Table 1

    Imaging tests for assessment of infective endocarditis

    Imaging testWhen to considerAdvantagesLimitations
    Transthoracic echocardiography (TTE)Suspected infective endocarditis in patients with risk factorsWidely available
    Relatively fast
    Provides hemodynamic information
    Noninvasive    		Decreased sensitivity for abscesses
    Can miss small vegetations
    Limited sensitivity for prosthetic valve infective endocarditis
    Operator-dependent
    Transesophageal echocardiography (TEE)Suspected infective endocarditis despite negative or inconclusive TTE
    Suspected infective endocarditis in patients with prosthetic valves    		Higher sensitivity than TTE for native-valve infective endocarditis, especially mitral valve infection
    Higher sensitivity than TTE in the presence of prosthetic valves or cardiac implanted electronic device (CIED)
    No radiation involved    		Patients must fast before test
    Cannot be used if oropharyngeal or esophageal structural abnormalities are present
    Sensitivity still decreased if prosthetic valve or CIED is present
    Anesthesia-associated risk
    Operator-dependent
    4-dimensional computed tomography (4D CT), with or without coronary angiographySuspected infective endocarditisin patients with negative orinconclusive TTE andcontraindications to TEE
    Perioperative assessment ofcoronary vasculature and aortictree in patients with knowninfective endocarditis    		Can detect local extension ofinfection, including abscess,fistula, and pseudoaneurysm
    Can incidentally detectpulmonary emboli
    Alternative to coronarycatheterization for preoperativeevaluation    		Can miss small valvular vegetations and perforations
    Iodinated contrast may exclude patients with renal dysfunction or iodine sensitivity
    Radiation exposure
    Arrhythmia reduces sensitivity due to motion artifact
    Fluorodeoxyglucose positron emission tomography (FDG-PET)Suspected infective endocarditisin patients with prosthetic valveor cardiac implanted electronicdevices and negative orinconclusive echocardiography
    Patients with persistentbacteremia and negative CTto identify nidus ofinfection for source control    		Identifies metastatic sites
    of infection
    Increases sensitivity of Duke criteria, especially in patients with cardiac implanted electronic devices
    Can identify source of bacteremia
    Better than echocardiography at diagnosing intracardiac abscesses and pseudoaneurysms    		False positives, particularly = 3months after cardiac surgery orwith vasculitis, tumors, foreignbodies, postsurgical inflammation
    False-negatives with antibioticsfor several days
    Limited diagnostic precision innative valve infective endocarditis
    Limited ability to evaluate infectionin brain, gingiva, kidneys
    Dietary carbohydrate restriction12–24 hours before study
    Expensive, limited availability
    Leukocyte scintigraphySame as for FDG-PETMore specific than FDG-PETLong study duration
    Expensive, limited availability
    Radiation exposure
    Cerebral magneticresonance imaging(MRI)Assess for mycotic aneurysm in patients otherwise deemed candidates for surgical intervention
    Assess for cerebral hemorrhage, which may affect management (surgery, anticoagulation)    		More sensitive than CT for detecting intracranial lesions
    Can lead to reclassification of patients (by adding a minor criterion), especially in those without neurologic symptoms    		Difficult in unstable patients
    Contraindicated in patients with noncompatible metal hardware
    Cannot be done with gadolinium enhancement in patients with contraindications (acute renal failure, chronic kidney disease with glomerular filtration rate < 30 mL/min/1.73 m2, dialysis)
    Cardiac MRIQuantify valvular regurgitation in patient with poor echocardiography images
    Assess intracardiac spread of disease in patient unable to receive contrast and with poor echocardiography images    		May be more sensitive than echocardiography for detecting vegetationsUnclear if better than CT
    Contraindicated in patients with noncompatible metallic hardware
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