title: Evaluation of vegetation size and its relationship with septic pulmonary embolism in tricuspid valve infective endocarditis: A real time 3DTEE study.
abstract: BACKGROUND
  Tricuspid valve infective endocarditis (TVIE) causes septic pulmonary embolism (PE). However, the impact of vegetation size on PE is not fully elucidated.
  
  
  METHODS
  In 26 consecutive patients with definite TVIE according to Duke criteria, we tested clinical, microbiological, and echocardiographic data including real time three-dimensional transesophageal echocardiography (3DTEE) as potential predictors of PE. 3DTEE measurement of maximum length of vegetation (MLV) was obtained with Advanced QLAB Quantification Software by cropping the 3D volume with the appropriate 2D plane to obtain the largest value. The standard two-dimensional transesophageal echocardiography (2DTEE) images were also evaluated to determine the MLV.
  
  
  RESULTS
  Pulmonary embolism occurred after TVIE diagnosis with 3DTEE assessment and initiation of antibiotic therapy in 12 patients (46.2%). The 3DTEE MLV was larger than the 2DTEE value with a mean difference of 3.6 mm (95% CI, 2.5-4.6 mm). The best cutoff value for prediction of PE was MLV ≥16.4 mm with 3DTEE and MLV ≥9.5 mm with 2DTEE. The positive predictive value increased from 76.9% to 90% when 3DTEE was used. The accuracy of classification of patients with PE increased from 80.6% to 84.9% with 3DTEE. On multivariate analysis, 3DTEE MLV ≥16.4 mm (odds ratio 20.5; 95% confidence interval 1.31-322; P=.031) was independently associated with the occurrence of PE after adjustment for age, sex, complex vegetation, and the number of vegetation-attached leaflets.
  
  
  CONCLUSIONS
  In TVIE, vegetation length is a strong predictor of the occurrence of PE. In combination with 2DTEE, 3DTEE may identify high-risk patients who will need a more aggressive therapeutic strategy.
authors.affiliation: Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
authors.forename: Hiroto
authors.identifier: http://orcid.org/0000-0002-6587-9584
authors.initials: H
authors.lastname: Utsunomiya
authors.affiliation: Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
authors.forename: Javier
authors.initials: J
authors.lastname: Berdejo
authors.affiliation: Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
authors.forename: Sayuki
authors.initials: S
authors.lastname: Kobayashi
authors.affiliation: Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
authors.forename: Hirotsugu
authors.initials: H
authors.lastname: Mihara
authors.affiliation: Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
authors.forename: Yuji
authors.initials: Y
authors.lastname: Itabashi
authors.affiliation: Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
authors.forename: Takahiro
authors.identifier: http://orcid.org/0000-0002-7172-8360
authors.initials: T
authors.lastname: Shiota
mesh_terms: D000328:Adult; D019560:Echocardiography, Three-Dimensional / Q000379:methods*; D017548:Echocardiography, Transesophageal / Q000379:methods*; D004696:Endocarditis / Q000150:complications* / Q000000981:diagnostic imaging*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011655:Pulmonary Embolism / Q000150:complications* / Q000382:microbiology; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D014261:Tricuspid Valve / Q000000981:diagnostic imaging / Q000382:microbiology
keywords: embolism; endocarditis; three-dimensional transesophageal echocardiography; tricuspid valve