The Preoperative Evaluation of Infective Endocarditis via 3-Dimensional Transesophageal Echocardiography

Diagnostic performance of contemporary transesophageal echocardiography with modern imaging for infective endocarditis

Background

Infective endocarditis (IE) is associated with high morbidity and mortality. Following an initial negative transesophageal echocardiogram (TEE), high clinical suspicion warrants repeat examination. We evaluated the diagnostic performance of contemporary TEE imaging for IE.

Methods

This retrospective cohort study included patients ≥18 years old undergoing ≥2 TEEs within 6 months, with confirmed diagnosis of IE based on Duke criteria, 70 in 2011 and 172 in 2019, were included. We compared the diagnostic performance of TEE for IE in 2019 versus 2011. The primary endpoint was the sensitivity of initial TEE to detect IE.

Results

Sensitivity of the initial TEE to detect endocarditis was 85.7% versus 95.3%, in 2011 and 2019, respectively (P=0.01). On multivariable analysis, initial TEE more frequently detected IE in 2019, compared to 2011 [odds ratio (OR): 4.06, 95% confidence intervals (CIs): 1.41-11.71, P=0.01]. Improved diagnostic performance was driven by improved detection of prosthetic valve infective endocarditis (PVIE), sensitivity 70.8% in 2011 versus 93.7% (P=0.009) in 2019. In 2019, TEEs more frequently utilized probes with higher frame rates/resolution, than 2011 (P<0.001). Three dimensional (3D) technology was utilized in 97.2% of initial TEEs in 2019, compared to 70.5% in 2011 (P<0.001).

Conclusions

Contemporary TEE was associated with improved diagnostic performance for endocarditis, driven by improved sensitivity for PVIE.

Virulent endocarditis due to Haemophilus parainfluenzae: A systematic review of the literature

BACKGROUND

Haemophilus parainfluenzae (HPI) belongs to the HACEK (Haemophilus spp., Aggregatibacter spp., Cardiobacterium spp., Eikenella spp., and Kingella spp.) group of organisms. The HACEK group of organisms are a part of the oropharyngeal flora and can cause invasive opportunistic infection such infective endocarditis (IE) in hosts with compromised immunological barriers.

AIM

To perform a 20-year systematic review of the literature characterizing the clinical presentation, epidemiology and prognosis of HPI IE.

METHODS

We performed a systematic review of Medline, Pubmed, Scopus and Embase from 2000 to 2022 to identify all cases of HPI IE.

RESULTS

Thirty-nine adult cases were identified. HPI IE was found to affect males slightly more than females and is common in patients with predisposing risk factors such as underlying valvular abnormalities. It mostly affected the mitral valve and had an indolent course; significantly sized vegetations (> 1 cm) developed in most cases. Central nervous system septic embolization was common. It had a favorable prognosis compared to staphylococcal and streptococcal IE.

CONCLUSION

Clinicians should be attentive to the indolent course of HPI IE and the presence of predisposing risk factors in order to allow for timely management.

Chronic rheumatic heart disease with recrudescence of acute rheumatic fever on histology: a case report

Background

Rheumatic heart disease (RHD) is endemic in sub-Saharan Africa where it is the leading cause of cardiovascular mortality in the young. Rheumatic heart disease results from recurrent episodes of acute rheumatic fever (ARF), which are often difficult to diagnose clinically. Acute rheumatic fever may be diagnosed based on the revised Jones Criteria 2015 for the diagnosis of ARF. Histologically, acute rheumatic valvulitis manifests with active inflammation characterized by lymphocytic infiltration, Aschoff bodies, and Anitschkow cells. Chronic rheumatic valvulitis is associated with neovascularization, and/or dystrophic calcification. The combination of histological features of both ARF and chronic RHD is a rare finding.

Case summary

Here we report on a case of a 59-year-old woman with mixed aortic and mitral valve disease of probable rheumatic aetiology (elevated C-reactive protein and prolonged PR interval) and with histological evidence of lymphocytic infiltration, Aschoff bodies, and fibrinoid necrosis admixed with features of chronic RHD.

Discussion

Cases of chronic RHD admixed with ARF are very rare; however, they should be considered in regions with a high prevalence of RHDs.

Imaging of Cardiac Infections: A Comprehensive Review and Investigation Flowchart for Diagnostic Workup

Infections of the cardiovascular system may present with nonspecific symptoms, and it is common for patients to undergo multiple investigations to arrive at the diagnosis. Echocardiography is central to the diagnosis of endocarditis and pericarditis. However, cardiac computed tomography (CT) and magnetic resonance imaging also play an additive role in these diagnoses; in fact, magnetic resonance imaging is central to the diagnosis of myocarditis. Functional imaging (fluorine-18 fluorodeoxyglucose-positron emission tomography/CT and radiolabeled white blood cell single-photon emission computed tomography/CT) is useful in the diagnosis in prosthesis-related and disseminated infection. This pictorial review will detail the most commonly encountered cardiovascular bacterial and viral infections, including coronavirus disease-2019, in clinical practice and provide an evidence basis for the selection of each imaging modality in the investigation of native tissues and common prostheses.

Spontaneous healing of a ruptured mycotic aneurysm of the posterior mitral leaflet: Unexpected resolution of a severe mitral regurgitation

Mycotic mitral valve aneurysm is an uncommon complication that rarely appears in isolated mitral valve endocarditis. The weakened aneurysmal wall may rupture, causing severe mitral regurgitation. In this situation surgery is essential. We present a case of a rare complicated mycotic posterior mitral aneurysm. After completing the antibiotic course for Streptococcus agalactiae infective endocarditis, an unexpected healing process within the aneurysm led to the virtual disappearance of the mitral regurgitation and remarkably changed the patient's clinical outcome. We emphasize the key role of three-dimensional transesophageal echocardiography, as it is becoming the reference imaging technique for infective endocarditis.

More Than a Simple Vegetation: The Trifecta of Mitral Valve Leaflet Perforation, Windsock Aneurysm, and Mitral Valve Abscess

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MV abscesses and aneurysms are uncommon complications of IE.

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Serial echocardiography is important to identify perivalvular complications.

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Three-dimensional transesophageal echocardiography has incremental value in diagnosis.

Added Value of Live 3-Dimensional Transesophageal Echocardiography During Procedures in Fontan Patients

3D transesophageal echocardiography (3D-TEE) has proven useful and accurate during some operating room (OR), interventional cardiac catheterization (Cath), and electrophysiologic (EP) procedures. The use of 3D-TEE during similar procedures in patients who have undergone Fontan surgery and its additional value have not been previously reported. To determine if live 3D-TEE during procedures post Fontan has added value, 3D-TEEs in 58 post-Fontan patients over a 5-year study period were reviewed. Additional information provided by 3D-TEE (over 2D-TEE) was classified into the following: A: new information which changed/refined the plan and 0: no new important information. Pre- and post-bypass OR 3D-TEEs were counted as one study. A total of 67 3D-TEEs (41 Cath, 13 OR, and 13 EP procedures) were performed. Median age was 14 years (6-39 years). Median weight was 47 kg (21-109 kg). In Cath procedures, only 2/41 (5%) were graded A (R to L atrial level shunt [Fontan leak], n = 1; thrombus in pulmonary artery stump, n = 1). In the OR, 6/13 (46%) were graded A (atrioventricular valvuloplasty, n = 1; neo-aortic valvuloplasty, n = 1; relief of systemic and pulmonary venous outflow obstruction, n = 2 and n = 2; respectively). In EP procedures, 4/13 (31%) were graded A (thrombus, n = 3; mapping for lead placement to assist in multisite pacing for dyssynchrony, n = 1). 3D-TEE of Fontan improved visualization and frequently added value in the OR/EP lab and may be helpful in select catheterization cases. Future studies with a larger sample could build on this data to identify when 3D-TEE will be most useful.

Diagnostic imaging in infective endocarditis: a contemporary perspective

INTRODUCTION

Infective endocarditis (IE) remains a diagnostic challenge. Prompt diagnosis is essential for accurate risk stratification and appropriate therapeutic decisions and surgical management. In recent years, the use of multimodal imaging has had a transformative effect on the diagnostic approach of IE in selected patients.

AREAS COVERED

This review assesses published literature on different imaging modalities for the diagnosis of IE published between 1 January 2009 and 1 February 2020. We illustrate the diagnostic approach to IE with three clinical cases.

EXPERT OPINION

Novel approaches to imaging for cardiac and extracardiac complications improve and individualize diagnosis, management, and prognosis in patients with suspected IE. The use of multimodal imaging should be guided by a multidisciplinary group of medical providers that includes infectious disease specialists, radiologists, cardiologists, and cardiothoracic surgeons.

Three dimensional transesophageal echocardiography: a missing link in infective endocarditis imaging?

The role of two dimensional (2D) echocardiography (ECHO) for the diagnosis and clinical decision making in infective endocarditis (IE) has been extensively studied and described in the medical literature. Some reports have demonstrated the incremental value of three dimensional (3D) transesophageal (TE) ECHO in the setting of IE. However, a systematic review focusing on the role of 3D imaging is lacking. In this manuscript, we examine the role of 3D TE ECHO in the diagnosis of IE. IE is a challenging disease in which 2D transthoracic (TT) and TE ECHO have complementary roles and are unequivocally the mainstay of diagnostic imaging. Still, 2D imaging has important limitations. Technological advances in 3D imaging allow for the reconstruction of real-time anatomical images of cardiac structure and function. 3D imaging has emerged as a diagnostic technique that overcame some of the limitations of 2D ECHO. Currently, both transthoracic and transesophageal echocardiography transducers are able to generate 3D images. However, 3D TE ECHO provides images of a higher quality in comparison to 3D TT ECHO, and is the best echocardiographic modality able to allow for a detailed anatomical imaging. 3D TE ECHO may represent the key adjunctive echocardiographic technique being able to positively impact on IE-related surgical planning and intervention and to facilitate the interaction between the surgeon and the imaging specialist. Importantly, 3D TE ECHO is not the recommended initial modality of choice for the diagnosis of IE; however, in highly specialized centers, it has become an important complementary technique when advanced surgical planning is required. Furthermore, anatomical imaging has become the link between the different techniques that play a role in IE imaging. In fact, both computed tomography and magnetic resonance allow three dimensional reconstruction. An important future goal should allow for the fusion among various imaging modalities. Our review highlights the role of 3D TE ECHO in IE imaging and emphasize where it offers incremental value.

3D echocardiography allows rapid and accurate surgical planning in complex aortic root abscess cases

Despite 3D echocardiography (3DE) acquiring significantly greater data than standard 2D echocardiography (2DE), it is underutilized in assessing cardiac anatomy and physiology. A key advantage is the ability of a single 3DE acquisition to be post-processed to generate volume rendered 3D models and an unlimited number of multiplanar reconstruction (MPR) images. We describe the case of a highly anxious patient with life-threatening complex aortic valve endocarditis and aortic root abscess, refusing transesophageal echocardiography (TOE) under general anaesthesia with tachycardia, breathlessness and acute kidney injury precluding accurate or safe gated (computed tomography) CT, who was comprehensively assessed with a rapid 3DE-TOE under sedation. This led to timely surgery and an excellent outcome for the patient.

Role of 3D Echocardiography in Cardiac Surgery: Strengths and Limitations

PURPOSE OF REVIEW

This review aims to highlight the general and specific strengths and limitations of intraoperative 3D echocardiography. This article explains the value of real-time three-dimensional transesophageal echocardiography (RT 3D TEE) during cardiac surgery and cardiac interventions.

RECENT FINDINGS

Recently published recommendations and guidelines include the use of RT 3D TEE. RT 3 D TEE provides additional value particularly for guidance during cardiac interventions (i.e., transcatheter mitral valve repair, left atrial appendix and atrial septal defect closures), assessment of the mitral valve in surgical repair, measurement of left ventricular outflow tract area for transcatheter valvular replacements, and estimating right and left ventricular volumes and function. The exact localization of paravalvular leakage is another strength of RT 3D TEE. The major limitation is the reduced temporal resolution compared to 2D TEE.

SUMMARY

Three-dimensional echocardiography is a powerful tool that improves communication and accurate measurements of cardiac structures.