Improving the Diagnosis of Infective Endocarditis in Prosthetic Valves and Intracardiac Devices With 18F-Fluordeoxyglucose Positron Emission Tomography/Computed Tomography Angiography: Initial Results at an Infective Endocarditis Referral Center.
BACKGROUND
The diagnosis of infective endocarditis (IE) in prosthetic valves and intracardiac devices is challenging because both the modified Duke criteria (DC) and echocardiography have limitations in this population. The added value of (18)F-fluorodeoxyglucose ((18)F-FDG) positron emission tomography (PET)/computed tomography (CT) and (18)F-FDG PET/CT angiography (PET/CTA) was evaluated in this complex scenario at a referral center with a multidisciplinary IE unit.


RESULTS
Ninety-two patients admitted to our hospital with suspected prosthetic valve or cardiac device IE between November 2012 and November 2014 were prospectively included. All patients underwent echocardiography and PET/CT, and 76 had cardiac CTA. PET/CT and echocardiography findings were evaluated and compared, with concordant results in 54% of cases (κ=0.23). Initial diagnoses with DC at admission, PET/CT, and DC+PET/CT were compared with the final diagnostic consensus reached by the IE Unit. DC+PET/CT enabled reclassification of 90% of cases initially classified as possible IE with DC and provided a conclusive diagnosis (definite/rejected) in 95% of cases. Sensitivity, specificity, and positive and negative predictive values were 52%, 94.7%, 92.9%, and 59.7% for DC; 87%, 92.1%, 93.6%, and 84.3% for PET/CT; and 90.7%, 89.5%, 92%, and 87.9% for DC+PET/CT. Use of PET/CTA yielded even better diagnostic performance values than PET/nonenhanced CT (91%, 90.6%, 92.8%, and 88.3% versus 86.4%, 87.5%, 90.2%, and 82.9%) and substantially reduced the rate of doubtful cases from 20% to 8% (P<0.001). DC+PET/CTA reclassified an additional 20% of cases classified as possible IE with DC+PET/nonenhanced CT. In addition, PET/CTA enabled detection of a significantly larger number of anatomic lesions associated with active endocarditis than PET/nonenhanced CT (P=0.006) or echocardiography (P<0.001).


CONCLUSIONS
(18)F-FDG PET/CT improves the diagnostic accuracy of the modified DC in patients with suspected IE and prosthetic valves or cardiac devices. PET/CTA yielded the highest diagnostic performance and provided additional diagnostic benefits.
From Departments of Cardiology (M.N.P., I.F.-G., M.T.G.-A., G.O., J.R.-P., D.G.-D., P.T.), Radiology (A.R., H.C.-C.), Infectious Diseases (N.-F.H., B.A.), Nuclear Medicine (L.G.-S., J.C.-C., S.A.-B.), Microbiology (J.J.G.), Cardiac Surgery (M.G.), and Neurology (O.M.-S.), Vall d´Hebron University Hospital and Research Institute, Universitat Autònoma de Barcelona (M.N.P., N.F.-H., J.R.-P., D.G.-D., J.C.-C., B.A., S.A.-B., P.T.), Spain; and CIBER de Epidemiología y Salud Pública, Madrid, Spain (I.F.G.). nachi_pizzi@yahoo.com.ar.
María N
MN
Pizzi
From Departments of Cardiology (M.N.P., I.F.-G., M.T.G.-A., G.O., J.R.-P., D.G.-D., P.T.), Radiology (A.R., H.C.-C.), Infectious Diseases (N.-F.H., B.A.), Nuclear Medicine (L.G.-S., J.C.-C., S.A.-B.), Microbiology (J.J.G.), Cardiac Surgery (M.G.), and Neurology (O.M.-S.), Vall d´Hebron University Hospital and Research Institute, Universitat Autònoma de Barcelona (M.N.P., N.F.-H., J.R.-P., D.G.-D., J.C.-C., B.A., S.A.-B., P.T.), Spain; and CIBER de Epidemiología y Salud Pública, Madrid, Spain (I.F.G.).
Albert
A
Roque
From Departments of Cardiology (M.N.P., I.F.-G., M.T.G.-A., G.O., J.R.-P., D.G.-D., P.T.), Radiology (A.R., H.C.-C.), Infectious Diseases (N.-F.H., B.A.), Nuclear Medicine (L.G.-S., J.C.-C., S.A.-B.), Microbiology (J.J.G.), Cardiac Surgery (M.G.), and Neurology (O.M.-S.), Vall d´Hebron University Hospital and Research Institute, Universitat Autònoma de Barcelona (M.N.P., N.F.-H., J.R.-P., D.G.-D., J.C.-C., B.A., S.A.-B., P.T.), Spain; and CIBER de Epidemiología y Salud Pública, Madrid, Spain (I.F.G.).
Nuria
N
Fernández-Hidalgo
From Departments of Cardiology (M.N.P., I.F.-G., M.T.G.-A., G.O., J.R.-P., D.G.-D., P.T.), Radiology (A.R., H.C.-C.), Infectious Diseases (N.-F.H., B.A.), Nuclear Medicine (L.G.-S., J.C.-C., S.A.-B.), Microbiology (J.J.G.), Cardiac Surgery (M.G.), and Neurology (O.M.-S.), Vall d´Hebron University Hospital and Research Institute, Universitat Autònoma de Barcelona (M.N.P., N.F.-H., J.R.-P., D.G.-D., J.C.-C., B.A., S.A.-B., P.T.), Spain; and CIBER de Epidemiología y Salud Pública, Madrid, Spain (I.F.G.).
Hug
H
Cuéllar-Calabria
From Departments of Cardiology (M.N.P., I.F.-G., M.T.G.-A., G.O., J.R.-P., D.G.-D., P.T.), Radiology (A.R., H.C.-C.), Infectious Diseases (N.-F.H., B.A.), Nuclear Medicine (L.G.-S., J.C.-C., S.A.-B.), Microbiology (J.J.G.), Cardiac Surgery (M.G.), and Neurology (O.M.-S.), Vall d´Hebron University Hospital and Research Institute, Universitat Autònoma de Barcelona (M.N.P., N.F.-H., J.R.-P., D.G.-D., J.C.-C., B.A., S.A.-B., P.T.), Spain; and CIBER de Epidemiología y Salud Pública, Madrid, Spain (I.F.G.).
Ignacio
I
Ferreira-González
From Departments of Cardiology (M.N.P., I.F.-G., M.T.G.-A., G.O., J.R.-P., D.G.-D., P.T.), Radiology (A.R., H.C.-C.), Infectious Diseases (N.-F.H., B.A.), Nuclear Medicine (L.G.-S., J.C.-C., S.A.-B.), Microbiology (J.J.G.), Cardiac Surgery (M.G.), and Neurology (O.M.-S.), Vall d´Hebron University Hospital and Research Institute, Universitat Autònoma de Barcelona (M.N.P., N.F.-H., J.R.-P., D.G.-D., J.C.-C., B.A., S.A.-B., P.T.), Spain; and CIBER de Epidemiología y Salud Pública, Madrid, Spain (I.F.G.).
María T
MT
Gonzàlez-Alujas
From Departments of Cardiology (M.N.P., I.F.-G., M.T.G.-A., G.O., J.R.-P., D.G.-D., P.T.), Radiology (A.R., H.C.-C.), Infectious Diseases (N.-F.H., B.A.), Nuclear Medicine (L.G.-S., J.C.-C., S.A.-B.), Microbiology (J.J.G.), Cardiac Surgery (M.G.), and Neurology (O.M.-S.), Vall d´Hebron University Hospital and Research Institute, Universitat Autònoma de Barcelona (M.N.P., N.F.-H., J.R.-P., D.G.-D., J.C.-C., B.A., S.A.-B., P.T.), Spain; and CIBER de Epidemiología y Salud Pública, Madrid, Spain (I.F.G.).
Gerard
G
Oristrell
From Departments of Cardiology (M.N.P., I.F.-G., M.T.G.-A., G.O., J.R.-P., D.G.-D., P.T.), Radiology (A.R., H.C.-C.), Infectious Diseases (N.-F.H., B.A.), Nuclear Medicine (L.G.-S., J.C.-C., S.A.-B.), Microbiology (J.J.G.), Cardiac Surgery (M.G.), and Neurology (O.M.-S.), Vall d´Hebron University Hospital and Research Institute, Universitat Autònoma de Barcelona (M.N.P., N.F.-H., J.R.-P., D.G.-D., J.C.-C., B.A., S.A.-B., P.T.), Spain; and CIBER de Epidemiología y Salud Pública, Madrid, Spain (I.F.G.).
Laura
L
Gracia-Sánchez
From Departments of Cardiology (M.N.P., I.F.-G., M.T.G.-A., G.O., J.R.-P., D.G.-D., P.T.), Radiology (A.R., H.C.-C.), Infectious Diseases (N.-F.H., B.A.), Nuclear Medicine (L.G.-S., J.C.-C., S.A.-B.), Microbiology (J.J.G.), Cardiac Surgery (M.G.), and Neurology (O.M.-S.), Vall d´Hebron University Hospital and Research Institute, Universitat Autònoma de Barcelona (M.N.P., N.F.-H., J.R.-P., D.G.-D., J.C.-C., B.A., S.A.-B., P.T.), Spain; and CIBER de Epidemiología y Salud Pública, Madrid, Spain (I.F.G.).
Juan J
JJ
González
From Departments of Cardiology (M.N.P., I.F.-G., M.T.G.-A., G.O., J.R.-P., D.G.-D., P.T.), Radiology (A.R., H.C.-C.), Infectious Diseases (N.-F.H., B.A.), Nuclear Medicine (L.G.-S., J.C.-C., S.A.-B.), Microbiology (J.J.G.), Cardiac Surgery (M.G.), and Neurology (O.M.-S.), Vall d´Hebron University Hospital and Research Institute, Universitat Autònoma de Barcelona (M.N.P., N.F.-H., J.R.-P., D.G.-D., J.C.-C., B.A., S.A.-B., P.T.), Spain; and CIBER de Epidemiología y Salud Pública, Madrid, Spain (I.F.G.).
José
J
Rodríguez-Palomares
From Departments of Cardiology (M.N.P., I.F.-G., M.T.G.-A., G.O., J.R.-P., D.G.-D., P.T.), Radiology (A.R., H.C.-C.), Infectious Diseases (N.-F.H., B.A.), Nuclear Medicine (L.G.-S., J.C.-C., S.A.-B.), Microbiology (J.J.G.), Cardiac Surgery (M.G.), and Neurology (O.M.-S.), Vall d´Hebron University Hospital and Research Institute, Universitat Autònoma de Barcelona (M.N.P., N.F.-H., J.R.-P., D.G.-D., J.C.-C., B.A., S.A.-B., P.T.), Spain; and CIBER de Epidemiología y Salud Pública, Madrid, Spain (I.F.G.).
Manuel
M
Galiñanes
From Departments of Cardiology (M.N.P., I.F.-G., M.T.G.-A., G.O., J.R.-P., D.G.-D., P.T.), Radiology (A.R., H.C.-C.), Infectious Diseases (N.-F.H., B.A.), Nuclear Medicine (L.G.-S., J.C.-C., S.A.-B.), Microbiology (J.J.G.), Cardiac Surgery (M.G.), and Neurology (O.M.-S.), Vall d´Hebron University Hospital and Research Institute, Universitat Autònoma de Barcelona (M.N.P., N.F.-H., J.R.-P., D.G.-D., J.C.-C., B.A., S.A.-B., P.T.), Spain; and CIBER de Epidemiología y Salud Pública, Madrid, Spain (I.F.G.).
Olga
O
Maisterra-Santos
From Departments of Cardiology (M.N.P., I.F.-G., M.T.G.-A., G.O., J.R.-P., D.G.-D., P.T.), Radiology (A.R., H.C.-C.), Infectious Diseases (N.-F.H., B.A.), Nuclear Medicine (L.G.-S., J.C.-C., S.A.-B.), Microbiology (J.J.G.), Cardiac Surgery (M.G.), and Neurology (O.M.-S.), Vall d´Hebron University Hospital and Research Institute, Universitat Autònoma de Barcelona (M.N.P., N.F.-H., J.R.-P., D.G.-D., J.C.-C., B.A., S.A.-B., P.T.), Spain; and CIBER de Epidemiología y Salud Pública, Madrid, Spain (I.F.G.).
David
D
Garcia-Dorado
From Departments of Cardiology (M.N.P., I.F.-G., M.T.G.-A., G.O., J.R.-P., D.G.-D., P.T.), Radiology (A.R., H.C.-C.), Infectious Diseases (N.-F.H., B.A.), Nuclear Medicine (L.G.-S., J.C.-C., S.A.-B.), Microbiology (J.J.G.), Cardiac Surgery (M.G.), and Neurology (O.M.-S.), Vall d´Hebron University Hospital and Research Institute, Universitat Autònoma de Barcelona (M.N.P., N.F.-H., J.R.-P., D.G.-D., J.C.-C., B.A., S.A.-B., P.T.), Spain; and CIBER de Epidemiología y Salud Pública, Madrid, Spain (I.F.G.).
Joan
J
Castell-Conesa
From Departments of Cardiology (M.N.P., I.F.-G., M.T.G.-A., G.O., J.R.-P., D.G.-D., P.T.), Radiology (A.R., H.C.-C.), Infectious Diseases (N.-F.H., B.A.), Nuclear Medicine (L.G.-S., J.C.-C., S.A.-B.), Microbiology (J.J.G.), Cardiac Surgery (M.G.), and Neurology (O.M.-S.), Vall d´Hebron University Hospital and Research Institute, Universitat Autònoma de Barcelona (M.N.P., N.F.-H., J.R.-P., D.G.-D., J.C.-C., B.A., S.A.-B., P.T.), Spain; and CIBER de Epidemiología y Salud Pública, Madrid, Spain (I.F.G.).
Benito
B
Almirante
From Departments of Cardiology (M.N.P., I.F.-G., M.T.G.-A., G.O., J.R.-P., D.G.-D., P.T.), Radiology (A.R., H.C.-C.), Infectious Diseases (N.-F.H., B.A.), Nuclear Medicine (L.G.-S., J.C.-C., S.A.-B.), Microbiology (J.J.G.), Cardiac Surgery (M.G.), and Neurology (O.M.-S.), Vall d´Hebron University Hospital and Research Institute, Universitat Autònoma de Barcelona (M.N.P., N.F.-H., J.R.-P., D.G.-D., J.C.-C., B.A., S.A.-B., P.T.), Spain; and CIBER de Epidemiología y Salud Pública, Madrid, Spain (I.F.G.).
Santiago
S
Aguadé-Bruix
From Departments of Cardiology (M.N.P., I.F.-G., M.T.G.-A., G.O., J.R.-P., D.G.-D., P.T.), Radiology (A.R., H.C.-C.), Infectious Diseases (N.-F.H., B.A.), Nuclear Medicine (L.G.-S., J.C.-C., S.A.-B.), Microbiology (J.J.G.), Cardiac Surgery (M.G.), and Neurology (O.M.-S.), Vall d´Hebron University Hospital and Research Institute, Universitat Autònoma de Barcelona (M.N.P., N.F.-H., J.R.-P., D.G.-D., J.C.-C., B.A., S.A.-B., P.T.), Spain; and CIBER de Epidemiología y Salud Pública, Madrid, Spain (I.F.G.).
Pilar
P
Tornos
D000368:Aged; D000792:Angiography / Q000379:methods*; D001145:Arrhythmias, Cardiac / Q000628:therapy; D017147:Defibrillators, Implantable / Q000382:microbiology*; D004452:Echocardiography; D004696:Endocarditis / Q000175:diagnosis* / Q000000981:diagnostic imaging; D005260:Female; D019788:Fluorodeoxyglucose F18; D006349:Heart Valve Diseases / Q000601:surgery; D006350:Heart Valve Prosthesis / Q000382:microbiology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010138:Pacemaker, Artificial / Q000382:microbiology*; D049268:Positron-Emission Tomography / Q000379:methods*; D011183:Postoperative Complications / Q000175:diagnosis; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D014057:Tomography, X-Ray Computed / Q000379:methods*
D019788:Fluorodeoxyglucose F18
endocarditis; heart; positron-emission tomography; tomography; valves