Echocardiography & Endocarditis by CaV02dI

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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
•   Surgical indications by Echocardiography
                Background
• Infection of endocardium
  – valve leaflets, congenital defects, chamber walls
    or chordae, prosthetic valves/conduits
                Background
• Infection of endocardium
  – valve leaflets, congenital defects, chamber walls
    or chordae, prosthetic valves/conduits
• Diagnosis: modified Duke criteria
                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

• 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
• 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
• 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
Characteristics of mass likely to be a vegetation:

• Texture: gray scale and reflectance of myocardium
         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 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 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 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
•   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
• 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
• 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 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
• Valvular regurgitation
• Secondary infection of other valves
• Leaflet perforation
               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
• 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
• 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
                                      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
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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