Elsevier

International Journal of Cardiology

Volume 248, 1 December 2017, Pages 396-402
International Journal of Cardiology

18F-FDG-PET/CT angiography in the diagnosis of infective endocarditis and cardiac device infection in adult patients with congenital heart disease and prosthetic material

https://doi.org/10.1016/j.ijcard.2017.08.008Get rights and content

Abstract

Objectives

Infective endocarditis (IE) and cardiac device infection (CDI) are a major complication in the growing number of patients with congenital heart disease (CHD) reaching adulthood. We aimed to evaluate the added value of 18F-FDG-PET/CT angiography (PET/CTA) in the diagnosis of IE-CDI in adults with CHD and intravascular or intracardiac prosthetic material, in whom echocardiography (ECHO) and modified Duke Criteria (DC) have limitations because of the patients' complex anatomy.

Methods

A prospective study was conducted in a referral center with multidisciplinary IE and CHD Units. PET/CTA and ECHO findings were compared in consecutive adult (≥ 18 years) patients with CHD who have prosthetic material and suspected IE-CDI. The initial diagnosis using the DC and the diagnosis with the additional PET/CTA data (DC + PET/CTA) were compared with the final diagnostic consensus established by an expert team at three months.

Results

Between November-2012 and April-2017, 25 patients (15 men; median age 40 years) were included. Cases were initially classified as definite in 8 (32%), possible in 14 (56%) and rejected in 3 (12%). DC + PET/CTA allowed reclassification of 12/14 (86%) cases initially identified as possible IE. The sensitivity, specificity, PPV, NPV, and accuracy of DC at IE suspicion were 39.1%/83.3%/90.4%/25.5%/61.2%, respectively. The diagnostic performance increased significantly with addition of PET/CTA data: 87%/83.3%/95.4%/61.5%/85.1%, respectively. PET/CTA also provided an alternative diagnosis in 3 patients with rejected IE, and detected pulmonary embolisms in 3 patients.

Conclusions

PET/CTA was a useful diagnostic tool in the complex group of adult patients with CHD who have cardiac or intravascular prosthetic material and suspected IE or CDI, providing added diagnostic value to the modified DC (increased sensitivity) and improving case classification.

Introduction

A growing number of patients with congenital heart disease (CHD) are reaching adulthood, and infective endocarditis (IE) and cardiac device infection (CDI) are major complications in this group, with an IE-related risk higher than in the general population [1], [2], [3]. In addition, patients with CHD have a complex anatomy, and their surgical treatment often requires implantation of a large amount of prosthetic material. These factors make them a special IE population with clear predisposing factors and a different epidemiological profile and outcome than that of the overall IE population [4], [5], especially when valve-containing prosthetics are present [6]. Use of the modified Duke criteria (DC) [7], which include echocardiography (ECHO) findings, is limited for diagnosing these patients, as the lesions visualized on ECHO are difficult to interpret. Hence, many cases of suspected IE are left without a conclusive diagnosis [8]. It would be of great value to have more accurate diagnostic imaging tools for use in this scenario.

Positron emission computed tomography with 18F-fluordeoxyglucose (18  F-FDG-PET/CT) associated with electrocardiogram (ECG)-gated cardiac CT-angiography (PET/CTA) combines the highest sensitivity to detect infection with the highest spatial resolution to define structural damage. Recent studies have reported a significant improvement in the diagnostic yield of the DC with the use of these techniques [9], [10], [11]. Therefore, the latest European guidelines have incorporated PET/CTA findings as major criterion in the diagnostic algorithms for IE [12].

The aim of this study was to evaluate the added value of PET/CTA in the diagnosis of IE and CDI in the specific population of adult patients with CHD and intravascular or intracardiac prosthetic material. To our knowledge, this is the first prospective evaluation of the utility of PET/CTA in this group of complex patients.

Section snippets

Methods

A prospective study investigating the usefulness of PET/CTA in adult (≥ 18 years) patients with CHD who have intravascular or cardiac prosthetic material and suspected IE-CDI was conducted at a tertiary referral hospital with an adult CHD unit and a multidisciplinary IE unit including cardiologists, infectious diseases physicians, cardiac imaging specialists, heart surgeons, neurologists, and microbiologists. The study protocol was approved by the hospital ethics committee, and written informed

Clinical and microbiological data

Between November 2012 and April 2017, 25 consecutive adult CHD patients who have prosthetic material and suspected IE-CDI were included (Supplemental Material-Table 1: Individual Patient Descriptions). Clinical and microbiological data are summarized in Table 1. Twenty-three (92%) patients had undergone surgical repair and 2 (8%) had not been treated surgically but had a cardiac device (automatic implantable defibrillator/resynchronizer).

Suspected IE-CDI were healthcare-associated in 12

Discussion

In our population of CHD patients with intravascular or intracardiac prosthetic material with suspected IE and cardiac device infection, we found a considerable improvement in the diagnostic yield when the DC and PET/CTA were used in combination. Diagnostic sensitivity was particularly enhanced, increasing from 39.1% to 89%, mainly because of improvements in IE-CDI case classification. There was a significant reduction in the number of possible IE-CDI cases (from 56% to 8%), which were mainly

Conclusions

18F-FDG-PET/CTA proved to be a useful diagnostic tool in patients with suspected IE or CDI and CHD who have prosthetic materials in whom the DC have a particularly low sensitivity for diagnosing IE-CDI. The additional information provided by this technique increased the diagnostic sensitivity of the modified DC from 39.1% to 87%, and resulted in a conclusive diagnosis in 92% of cases. Thus, it seems reasonable to encourage its use in this population in cases of doubtful clinical or

Funding sources

This study was partially funded by the Integrated Excellence Project PIE-0013 and supported by Plan Nacional de I + D + i 2013–2016 and networks for cooperative research on cardiovascular (RECAVA RD16/0042/0021) and infectious diseases (REIPI RD16/0016/0003) of Instituto de Salud Carlos III, and co-financed by the European Development Regional Fund (FEDER) 2014–2020, “A way to achieve Europe”, Operative program Intelligent Growth 2014–2020.

Disclosures

None declared.

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