Echocardiography endocarditis
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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

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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


Surgery in ie

Surgery in IE


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.


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