Diagnostic value of harmonic transthoracic echocardiography in native valve infective endocarditis: comparison with transesophageal echocardiography

Login or register to view PDF.
Abstract

Abstract

Background
Although echocardiography has been incorporated into the diagnostic algorithm of patients with suspected infective endocarditis (IE), systematic usage in clinical practice remains ill defined. To determine the diagnostic accuracy of detecting vegetations using harmonic transthoracic echocardiography (hTTE) as compared to transesophageal echocardiography (TEE) in patients with an intermediate likelihood of native valve IE.

Pages

Methods
Between 2004 and 2005, 36 consecutive inpatients with an intermediate likelihood of disease were prospectively evaluated by hTTE and TEE.

Results
Of 36 patients (21 males with a mean age of 57 ± 15 years, range 32 to 86 years), 19 patients had definite IE by TEE. The sensitivity for the detection of vegetations by hTTE was 84%, specificity of 88%, positive predictive value (PPV) of 89% and negative predictive value (NPV) of 82%. The association between hTTE and TTE interpretation for the presence and absence of vegetations were high (kappa = 0.90 and 0.85 respectively).

Conclusion
In patients with an intermediate likelihood of native valve IE, TTE with harmonic imaging provides diagnostic quality images in the majority of cases, has excellent concordance with TEE and should be recommended as the first line test.

Background
Infective endocarditis (IE) is a diagnostic and therapeutic challenge that is associated with high patient morbidity and mortality. [1] The diagnosis and management of IE have changed dramatically over the past 40 years, in particular the complementary use of echocardiography. [2,3] In addition to positive blood cultures and a new regurgitant murmur, echocardiographic findings has become one of the major Duke criteria for IE providing objective evidence of endocardial involvment. [3] Despite the higher sensitivity and specifity of transesophageal echocardiography (TEE) in the detection of valvular vegetations and characterization of complications, [4-7] transthoracic echocardiography (TTE) remains the initial procedure of choice in patients with suspected IE, due to its noninvasive nature and low cost. [8]

Although echocardiography has been incorporated into the diagnostic approach for patients with suspected IE, systematic usage in clinical practice is still not optimally defined. In patients with a high clinical likelihood of IE, the practical role of TTE for diagnostic purposes is low. [9,10] In the same context, echocardiography is often requested for patients with a transient fever, a nonregurgitant murmur, or both, who have a very low likelihood for the disease, with a low diagnostic yield. [9,10] Strict adherence to indications for TTE and TEE may help to facilitate more appropriate use and accurate diagnosis in patients who are most likely to benefit from screening echocardiography, in those patients with intermediate likelihood of the disease. [10]

Pages

References
  1. Bayer AS, Bolger AF, Taubert KA, Wilson W, Steckelberg J, Karchmer AW, Levison M, Chambers HF, Dajani AS, Gewitz MH, Newburger JW, Gerber MA, Shulman ST, Pallasch TJ, Gage TW, Ferrieri P: Diagnosis and management of infective endocarditis and its complications. Circulation 1998, 98:2936-48.
  2. Evangelista A, Gonzalez-Alujas : Echocardiography in infective endocarditis. Heart 2004, 90:614-617.
  3. Durack DT, Lukes AS, Bright DK: New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Am J Med 1994, 96:200-9.
  4. Shively BK, Gurule FT, Roldan CA, Leggett JH, Schiller NB: Diagnostic value of transesophageal compared with transthoracic echocardiography in infective endocarditis. J Am Coll Cardiol 1991, 18:391-397.
  5. Pedersen WR, Walker M, Olson JD, Gobel F, Lange HW, Daniel JA, Rogers J, Longe T, Kane M, Mooney MR: Value of transesophageal echocardiography as an adjunct to transthoracic echocardiography in evaluation of native and prosthetic valve endocarditis. Chest 1991, 100:351-366.
  6. Shapiro SM, Young E, De Guzman S, Ward J, Chiu CY, Ginzton LE, Bayer AS: Transesophageal echocardiography in diagnosis of infective endocarditis. Chest 1994, 105:377-382.
  7. Birmingham GD, Rahko PS, Ballantyne F: Improved detection of infective endocarditis with transesophageal echocardiography. Am Heart J 1992, 123:774-781.
  8. Murphy JG, Foster-Smith KF: Management of complications of infective endocarditis with emphasis on echocardiographic findings. Infect Dis Clin North Am 1993, 7:153-6.
  9. Jassal DS, Neilan TG, Pradhan AD, Lynch KE, Vlahakes G, Agnihotri A, Picard MH: Surgical Management of Infective Endocarditis: Early Predictors of Short Term Morbidity and Mortality. Ann Thor Surg 2006, 82:524-9.
  10. Jassal DS, Lee C, Silversides C, Tam JW: Can structured clinical assessment using a modified Duke's criteria improve appropriate use of echocardiography in patients with suspected infective endocarditis? Can J Cardiol 2003, 19:1017-22.
  11. Thomas JD, Rubin DN: Tissue harmonic imaging: why does it work? J Am Soc Echocardiogr 1998, 11:803-8.
  12. Turner SP, Monaghan MJ: Tissue harmonic imaging for standard left ventricular measurements: Fundamentally flawed? Eur J Echocardiography 2006, 7:9-15.
  13. Habib G, Derumeaux G, Avierinos JF, Casalta JO, Jamal F, Volot F, Garcia M, Lefevre J, Biou F, Maximovitch-Rodaminoff A, Fournier PE, Ambrosi P, Velut JG, Cribier A, Harle JR, Weiller PJ, Raoult D, Luccioni R: Value and limitation of the Duke criteria for the diagnosis of infective endocarditis. J Am Coll Cardiol 1999, 33:2023-29.
  14. Van Wijk MC, Thijssen JM: Performance testing of medical ultrasound equipment: fundamental vs. harmonic mode. Ultrasonics 2002, 40:585-91.
  15. Prior DL, Jaber WA, Homa DA, Thomas JD, Mayer Sabik E: Impact of tissue harmonic imaging on the assessment of rheumatic mitral stenosis. Am J Cardiol 2000, 86:573-6.
  16. Tsujita-Kuroda Y, Xhang G, Sumita Y, Hirooka K, Hanatani A, Nakatani S, Yasumura Y, Miyatake K, Yamagishi M: Validity and reproducibility of echocardiographic measurement of left ventricular ejection fraction by acoustic quantification with tissue harmonic imaging technique. J Am Soc Echocardiogr 2000, 13:300-5.
  17. Mansencal N, Bordachar P, Chatellier G, Redheuil A, Diebold B, Abergel E: Comparison of accuracy of left ventricular echocardiographic measurement by fundamental imaging versus second harmonic imaging. Am J Cardiol 2003, 91:1037-9.
  18. Chirillo F, Pedrocco A, De Leo A, Bruni A, Totis O, Meneghetti P, Stritoni P: Impact of harmonic imaging on transthoracic echocardiographic identification of infective endocarditis and its complications. Heart 2005, 91:329-333.
  19. Tam JW, Manji RA, Shaikh N, Morris A: Diagnostic approach to endocarditis. Endocarditis: Diagnosis and Management 2006:63-77.