echocardiography endocarditis
Download
Skip this Video
Download Presentation
Echocardiography & Endocarditis

Loading in 2 Seconds...

play fullscreen
1 / 45

Echocardiography & Endocarditis - PowerPoint PPT Presentation


  • 107 Views
  • Uploaded on

Echocardiography & Endocarditis . Echo Imaging Conference 1/20/10 Ethan Ellis, MD. Overview. Background Diagnosis ACC/AHA indications for Echo TTE versus TEE Diagnostic Echo criteria Echocardiographic estimation of outcome Intracardiac complications of endocarditis

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' Echocardiography & Endocarditis ' - xaria


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
echocardiography endocarditis

Echocardiography & Endocarditis

Echo Imaging Conference

1/20/10

Ethan Ellis, MD

overview
Overview
  • Background
  • Diagnosis
  • ACC/AHA indications for Echo
  • TTE versus TEE
  • Diagnostic Echo criteria
  • Echocardiographic estimation of outcome
  • Intracardiac complications of endocarditis
  • Surgical indications by Echocardiography
background
Background
  • Infection of endocardium
    • valve leaflets, congenital defects, chamber walls or chordae, prosthetic valves/conduits
background1
Background
  • Infection of endocardium
    • valve leaflets, congenital defects, chamber walls or chordae, prosthetic valves/conduits
  • Diagnosis: modified Duke criteria
background2
Background
  • Infection of endocardium
    • valve leaflets, congenital defects, chamber walls or chordae, prosthetic valves/conduits
  • Diagnosis: modified Duke criteria
  • No noninvasive technique can definitively diagnose
    • Echocardiography has high sensitivity for IE and intracardiac abscess
    • Mandatory in the diagnosis and treatment of IE
  • ACC/AHA 2006 guidelines on valvular heart disease include recommendations for Echo use in native and prosthetic valve IE
goals of echo in possible ie
Goals of Echo in Possible IE
  • Identify, localize, and characterize masses consistent with vegetations
  • Identify new valvular regurgitation
  • Examine prosthetic valve stability
  • Apply criteria to judge prognosis once vegetation identified
accuracy of tte
Accuracy of TTE
  • Meta analysis 1984: 641 pts*
    • Mean sensitivity of 79% for detecting veg’s
  • More recently, decreased sensitivity despite tech improvements
  • 7 studies, 1989-1994, Mean sensitivity of 62% 4-11
    • ? d/t more rigorous case selection or d/t decreased TTE scrutiny now with TEE
  • Limitations
    • Underestimates size and complexity of large veg’s
    • May fail to detect small veg’s (< 3 mm)

*O\'Brien, JT, Geiser, EA. Infective endocarditis and echocardiography. Am Heart J 1984; 108:386

accuracy of tee
Accuracy of TEE
  • More invasive and expensive than TTE
  • High sensitivity in detecting and defining valve vegetations
    • Same 7 studies from 1989-1994, sensitivity 92% (compared to 62%)4-11
    • 5 studies w/ similar results for sensitivity also revealed high specificity for TEE and TTE (93% vs 46% sensitivity, 96% vs 95% specificity) 4,8,10-12
  • ACC/AHA guidelines, main role of TEE is:
    • Nondiagnostic TTE
    • Prosthetic valve endocarditis
    • Assessment of complications
diagnostic echo criteria
Diagnostic Echo criteria

Characteristics of mass likely to be a vegetation:

  • Texture: gray scale and reflectance of myocardium
diagnostic echo criteria1
Diagnostic Echo criteria

Characteristics of mass likely to be a vegetation:

  • Texture: gray scale and reflectance of myocardium
  • Location: upstream side of valve in path of jet or on prosthetic material
diagnostic echo criteria2
Diagnostic Echo criteria

Characteristics of mass likely to be a vegetation:

  • Texture: gray scale and reflectance of myocardium
  • Location: upstream side of valve in path of jet or on prosthetic material
  • Motion: choatic and orbiting, independent of valve motion
    • Prolapse into upstream chamber (i.e. MV mass into LA in systole)
diagnostic echo criteria3
Diagnostic Echo criteria

Characteristics of mass likely to be a vegetation:

  • Texture: gray scale and reflectance of myocardium
  • Location: upstream side of valve in path of jet or on prosthetic material
  • Motion: choatic and orbiting, independent of valve motion
    • Prolapse into upstream chamber (i.e. MV mass into LA in systole)
  • Shape: lobulated, amorphous
  • Accompanying abnormalities:
    • abscess, pseudoaneurysm, fistula, prosthetic dehiscence, paravalvular leak, new regurgitant lesion
diagnostic echo criteria4
Diagnostic Echo criteria

Characteristics of mass unlikely to be vegetation:

  • Texture: reflectance of calcium or pericardium (white)
  • Location: outflow tract attachment, downstream surface of valve
  • Shape: stringy or hair-like strands with narrow attachment
  • Lack of accompanying turbulent flow or regurgitation
false positives
False Positives
  • Most common on TEE
  • Lambl’s excrescences
  • Strands on sewing rings of prosthetics
  • Free suture
  • Redundant chordae, false tendons in LV
  • Chiari’s remnant in RA
  • Chordal insertion into normal MV
  • All of above tend to be highly reflective with echodensity similar to pericardium or aortic root. Dense, fibrotic, non-vibratory nature
false negatives
False Negatives
  • TTE>TEE
    • High sensitivity of TEE (92-94%)
  • Cannot definitively rule out endocarditis
  • Low likelihood of IE if negative TEE in intermediate probability patient
  • In patients at high risk for IE (prosthetic valve, unexplained bacteremia), repeat examination reasonable
echo estimation of outcome
Echo Estimation of Outcome
  • TTE:
    • 1991 Retrospective study. 204 pts with clinical criteria for IE.*
    • Clinical complications (drug failure, new CHF, embolization, surgery, death) compared to vegetation characteristics
    • Overall complication incidence 55%
    • Rates similar between native and prosthetic valves as well as between MV, TV, and AV
    • Size of vegetation most powerful predictor of complication
      • 10% if 6 mm vegetation, 50% if 11mm vegetation, almost 100% if > 16 mm
    • Complications more frequent with higher grades of mobility and lesion extent
    • Vegetation consistency did not predict complications (except for calcified lesions which had no associated complications)

*Sanfilippo, AJ, Picard, MH, Newell, JB, et al. Echocardiographic assessment of patients with infectious endocarditis: Prediction of risk

for complications. J Am Coll Cardiol 1991; 18:1191.

echo estimation of outcome1
Echo Estimation of Outcome
  • TEE:
    • Observations on TTE not directly applicable to TEE since given vegetation likely to appear larger on TEE
    • 105 pts with IE, 1989*:
      • vegetation > 10 mm = increased incidence of embolization (47% v 19%, p<0.01)
      • Association particularly strong for MV endocarditis
      • Vegetation size and location did not predict other rates of complications (CHF, death)
    • 178 pts with IE, 2002+:
      • Vegetation mobility confers additional risk beyond vegetation size
      • Embolic incidence higher with vegetation > 15 mm (70% vs 27%) and when vegetation moderately or severely mobile (62% vs 20% compared to low mobility)
      • Embolic rate 83% with large and severely mobile vegetations
  • Observational studies suggest risk of embolism declines after institution of antibiotic therapy
  • Echo predictors still apply after initiation of antibiotics
    • Greater vegetation size and mobility still predicted late embolic events
    • Increase in vegetation size after antibiotic start also predicted prolonged healing phase and a higher embolic risk

*Mugge, A, Daniel, WG, Frank, G, Lichtlen, PR. Echocardiography in infective endocarditis: reassessment of prognostic implications of

vegetation size determined by the transthoracic and the transesophageal approach. J Am Coll Cardiol 1989; 14:631.

+Di Salvo, G, Habib, G, Pergola, V, et al. Echocardiography predicts embolic events in infective endocarditis. J Am Coll Cardiol 2001; 37:1069.

intracardiac complications
Intracardiac Complications
  • Valvular regurgitation
  • Secondary infection of other valves
  • Leaflet perforation
intracardiac complications1
Intracardiac Complications
  • Valvular regurgitation
  • Secondary infection of other valves
  • Leaflet perforation
  • Perivalvular abscess or fistula
    • Early invasion  cellulitis (echodense thickening of perivalvular tissue)  Necrosis and inflammation  abscess cavity
    • Abscess most likely with staph aureus
    • Risk of fistula formation
    • Abscess formation  increase in morbidity and mortality
    • TEE >TTE: 118 pts with IE, 1991, 44 with abscess at surgery/autopsy. 87% vs 28% sensitivity*
    • TEE still imperfect. Additional series 2007 showed TEE detecting only 48% of abscesses (21 of 44 pts)+

*Daniel, WG, Mugge, A, Martin, RP, et al. Improvement in the diagnosis of abscesses associated with endocarditis by transesophageal

echocardiography. N Engl J Med 1991; 324:795.

+Hill, EE, Herijgers, P, Claus, P, et al. Abscess in infective endocarditis: the value of transesophageal echocardiography and outcome:

a 5-year study. Am Heart J 2007; 154:923.

right sided endocarditis
Right Sided Endocarditis
  • Tricuspid valve vegetations most common in IV drug users
  • Most caused by staph aureus
  • Infrequently, R sided endocarditis due to involvement of PV
    • Often diagnosed only by TEE
    • most literature limited to single case reports
  • Most reports of R sided endocarditis have used TTE
  • In 48 IVDU pts with suspected IE, 22 with vegetations+
    • TTE and TEE equally sensitive and specific
    • TEE found no vegetations which were overlooked by TTE although vegetation usually better characterized by TEE

+San Roman, JA, Vilacosta, I, Zamorano, JL, et al. Transesophageal echocardiography in right-sided endocarditis. J Am Coll Cardiol

1993; 21:1226.

prosthetic valve endocarditis
Prosthetic Valve Endocarditis
  • Findings suggestive of IE in prosthetic valves:
    • Vegetation
    • perivalvular abscess and fistula formation
    • impaired leaflet motion
    • valve rocking suggesting valve dehiscence
    • Perivalvular regurgitation.

* Must compare to prior. If no, moderate-severe suggestive of IE (not mild)

  • Echo evaluation can be limited by highly reflective prosthetic materials which block the passage of ultrasound
    • TEE has higher sensitivity than TTE (82-86% vs 36-43%)13-16
    • NPV close to 100% for TEE in native valve endocarditis but not for prosthetic valves making clinical assessment especially important
  • According to most recent ACC/AHA guidelines, TEE should be first line diagnostic test for possible IE in prosthetic valves
summary
Summary
  • Echocardiogram part of major criteria in Modified Duke Criteria
  • Goals to aid in diagnosis, localize vegetations, assess for complications of IE
  • Mass texture, location, motion, shape, and associated abnormalities important
  • Vegetation size and mobility correlated with embolic complications in multiple studies
  • TEE more sensitive than TTE. Both highly specific.
  • NPV high for TEE. Role for repeat imaging in high risk patients
  • TEE better at detecting IE complications such as abscess, fistula, and leaflet perforation
  • TTE = TEE in detecting R sided endocarditis with exception of PV involvement
  • TEE > TTE for prosthetic valve IE and should be pursued directly
  • ACC/AHA guidelines from 2006 include recommendations for use of TTE/TEE
    • Generally TTE is preferred
    • Class I indications TEE: nondiagnostic TTEs, better assessment of abscess/complications, prosthetic IE
    • Class IIA indications TEE: persistent staph bacteremia without clear source
  • ACC/AHA for surgical intervention (severe valve dysfunction, abscess, other penetrating lesion)
references
References

1. Bonow, RO, Carabello, BA, Chatterjee, K, et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing committee to revise the 1998 guidelines for the management of patients with valvular heart disease). J Am Coll Cardiol 2006; 48:e1.

2. Bonow, RO, Carabello, BA, Chatterjee, K, et al. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2008; 118:e523.

3. Role of Echocardiography in Infective Endocarditis. UpToDate. 2010.

4. Shively, BK, Gurule, FT, Roldan, CA, et al. Diagnostic value of transesophageal compared with transthoracic echocardiography in infective endocarditis. J Am Coll Cardiol 1991; 18:391.

5. Mugge, A, Daniel, WG, Frank, G, Lichtlen, PR. Echocardiography in infective endocarditis: reassessment of prognostic implications of vegetation size determined by the transthoracic and the transesophageal approach. J Am Coll Cardiol 1989; 14:631.

6. Jaffe, WM, Morgan, DE, Pearlman, AS, Otto, CM. Infective endocarditis, 1983-1988: echocardiographic findings and factors influencing morbidity and mortality. J Am Coll Cardiol 1990; 15:1227.

7. Burger, AJ, Peart, B, Jabi, H, Touchon, RC. The role of two-dimensional echocardiology in the diagnosis of infective endocarditis [corrected] [published erratum appears in Angiology 1991 Sep;42(9):765]. Angiology 1991; 42:552.

8. Pedersen, WR, Walker, M, Olson, JD, et al. Value of transesophageal echocardiography as an adjunct to transthoracic echocardiography in evaluation of native and prosthetic valve endocarditis. Chest 1991; 100:351.

9. Daniel, WG, Mugge, A, Martin, RP, et al. Improvement in the diagnosis of abscesses associated with endocarditis by transesophageal echocardiography. N Engl J Med 1991; 324:795.

10. Sochowski, RA, Chan, KL. Implication of negative results on a monoplane transesophageal echocardiographic study in patients with suspected infective endocarditis. J Am Coll Cardiol 1993; 21:216.

11. Shapiro, SM, Young, E, De Guzman, S, et al. Transesophageal echocardiography in diagnosis of infective endocarditis. Chest 1994; 105:377.

12. Birmingham, GD, Rahko, PS, Ballantyne, FD. Improved detection of infective endocarditis with transesophageal echocardiography. Am Heart J 1992; 123:774.

13. Zabalgoitia, M, Garcia, M. Pitfalls in the echo-Doppler diagnosis of prosthetic valve disorders. Echocardiography 1993; 10:203.

14. Daniel, WG, Mugge, A, Grote, J, et al. Comparison of transthoracic and transesophageal echocardiography for detection of abnormalities of prosthetic and bioprosthetic valves in the mitral and aortic positions. Am J Cardiol 1993; 71:210.

15. Alton, ME, Pasierski, TJ, Orsinelli, DA, et al. Comparison of transthoracic and transesophageal echocardiography in evaluation of 47 Starr-Edwards prosthetic valves. J Am Coll Cardiol 1992; 20:1503.

16. Roe, MT, Abramson, MA, Li, J, et al. Clinical information determines the impact of transesophageal echocardiography on the diagnosis of infective endocarditis by the Duke criteria. Am Heart J 2000; 139:945.

ad