We conducted this prospective, randomized trial involving patients with infective endocarditis who were candidates for both early surgery and. The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI) Brain CT may also help in distinguishing primary SAH from traumatic brain injury, but the aneurysmal pattern of haemorrhage is not always immediately appreciated in. Improving the Diagnosis of Infective Endocarditis in Prosthetic Valves and Intracardiac Devices With 1. F- Fluordeoxyglucose Positron Emission Tomography/Computed Tomography Angiography. CLINICAL PERSPECTIVEAbstract. Background—The diagnosis of infective endocarditis (IE) in prosthetic valves and intracardiac devices is challenging because both the modified Duke criteria (DC) and echocardiography have limitations in this population. The added value of 1. F- fluorodeoxyglucose (1. F- FDG) positron emission tomography (PET)/computed tomography (CT) and 1. F- FDG PET/CT angiography (PET/CTA) was evaluated in this complex scenario at a referral center with a multidisciplinary IE unit. Methods and Results—Ninety- two patients admitted to our hospital with suspected prosthetic valve or cardiac device IE between November 2. November 2. 01. 4 were prospectively included. All patients underwent echocardiography and PET/CT, and 7. CTA. PET/CT and echocardiography findings were evaluated and compared, with concordant results in 5. Initial diagnoses with DC at admission, PET/CT, and DC+PET/CT were compared with the final diagnostic consensus reached by the IE Unit. DC+PET/CT enabled reclassification of 9. IE with DC and provided a conclusive diagnosis (definite/rejected) in 9. Sensitivity, specificity, and positive and negative predictive values were 5. DC; 8. 7%, 9. 2. 1%, 9. PET/CT; and 9. 0. DC+PET/CT. Use of PET/CTA yielded even better diagnostic performance values than PET/nonenhanced CT (9. P< 0. 0. 01). DC+PET/CTA reclassified an additional 2. IE with DC+PET/nonenhanced CT. In addition, PET/CTA enabled detection of a significantly larger number of anatomic lesions associated with active endocarditis than PET/nonenhanced CT (P=0. P< 0. 0. 01). Conclusions—1. F- FDG PET/CT improves the diagnostic accuracy of the modified DC in patients with suspected IE and prosthetic valves or cardiac devices. PET/CTA yielded the highest diagnostic performance and provided additional diagnostic benefits. Introduction. The diagnosis of infective endocarditis (IE) is a clinical challenge because of its varying clinical presentation, the different microorganisms involved, and the underlying patient characteristics. Therefore, the diagnosis and management of IE require a collaborative approach by cardiologists, infectious disease physicians, cardiac imaging specialists, heart surgeons, and microbiologists. Despite major advances in both diagnostic and therapeutic procedures for this condition, IE remains associated with a poor prognosis, and its incidence and mortality rates have not decreased in the last 3. Editorial see p 1. Clinical Perspective on p 1. Approximately 2. 0% of IE patients have intracardiac devices or prosthetic valves. These patients make up a special IE population with a clear predisposing factor, different epidemiological profile, and higher mortality. Use of the traditional modified Duke criteria (DC) is limited in these patients because the interpretation of the lesions seen on echocardiography is complex and many cases of suspected IE are left without a conclusive diagnosis. Hence, the development of new diagnostic tools for IE is clinically important. Positron emission tomography (PET) with 1. F- fluorodeoxyglucose (1. F- FDG) is a potentially useful technique for detecting infection because inflammatory leukocytes express a high density of glucose transporters and are highly metabolically active. The role of oral antibiotic therapy in treating infective endocarditis (IE) is not well established. Size of Treatment Effect : CLASS I Benefit >>> Risk Procedure/Treatment SHOULD be performed/ administered: CLASS IIa Benefit >> Risk Additional studies with focused. Furthermore, newer systems can perform gated cardiac computed tomography (CT) angiography (CTA), thus combining the high sensitivity of 1. F- FDG PET/CT to detect inflammation with the high spatial resolution of cardiac CTA to define structural damage. Although guidelines have not included this technique in the diagnostic algorithms of IE to date,7,8 some recent studies have reported encouraging results in patients with intracardiac devices. The aim of this study was to evaluate the clinical value of 1. F- FDG PET/CT and 1. F- FDG PET/CTA for the diagnosis of IE in patients with prosthetic valves or intracardiac devices. Methods. A prospective study was conducted at a cardiac surgery referral center with a multidisciplinary IE unit including cardiologists, infectious diseases physicians, cardiac imaging specialists, heart surgeons, neurologists, and microbiologists. All patients with prosthetic valves or cardiac devices consecutively admitted for suspected IE were included. IE was suspected on the basis of the presence of at least 1 of the following criteria: persistent or recurrent temperature > 3. The only exclusion criteria were severe hemodynamic instability and conditions requiring urgent surgery. Although it is known that a recent prosthetic valve replacement can lead to postoperative inflammatory activity, there was no restriction on the time interval between surgery and PET/CT (Table I and the Methods section in the online- only Data Supplement). All patients underwent PET/CT with a standard non–ECG- gated non–contrast- enhanced whole- body CT scan (PET/NECT), and those with no contraindications additionally underwent PET/CTA. The study was approved by the Institutional Review Board, and written informed consent was obtained from all participating patients. Clinical and Microbiological Data. Demographics, diabetes history and other relevant clinical data, date of onset and type of symptoms, and all data related to heart disease history, including cardiac surgery details, were collected at hospital admission. Basic laboratory assays included renal function and leukocyte count. Blood cultures were performed on a Bac. T/ALERT 3. D system (bio. M. Each blood culture consisted of a pair of bottles: FAN aerobic and FAN anaerobic medium. When the patient’s condition allowed it, a minimum of 4 pairs of blood cultures were performed, 2 pairs at admission and 2 additional pairs at least 1. If the patient’s clinical status was critical, 1 pair was extracted every half- hour in the first hour, and antibiotic treatment was then immediately started. If blood cultures were negative, serological tests were performed (Bartonella, Brucella, Coxiella burnetii, Chlamydophila spp., and Legionella). In all patients undergoing surgery, explanted tissues were cultured. In selected tissue samples, direct detection and identification of bacteria were carried out by 1. S r. RNA gene amplification and sequencing. Molecular identification of Streptococcus spp. In patients with an initially doubtful or negative echocardiography, a second study was performed 7 days later. The echocardiography included assessments of valve function, vegetations (shape, size, and number), and periannular complications (abscess, pseudoaneurysm, perivalvular leak). PET/CT and PET/CTA Techniques. To facilitate visualization of abnormal 1. F- FDG uptake in presumed infected sites, suppression of 1. F- FDG by normal myocardium suppression was carried out by a fasting period of at least 1. IU/kg heparin 1. 5 minutes before 1. F- FDG injection (3. No adverse effects occurred with the use of this protocol. A full description of the PET/CT and PET/CTA protocol is included in the online- only Data Supplement. Briefly, 6. 0 minutes after 1. F- FDG administration, images were acquired with a PET/CT scanner (SIEMENS Biograph m. CT 6. 4S), corrected for soft tissue attenuation, and reconstructed with the iterative True. X+TOF (ultrahigh- definition PET) algorithm. The sequential acquisition protocol was as follows: (1) whole- body PET/CT for 2 minutes per bed position, (2) gated cardiac PET localized 8 minutes per bed position to improve evaluation of the region of interest, and (3) ECG- gated cardiac CTA in all patients without renal impairment (creatinine level < 2 mg/d. L)1. 3 who were able to perform a breath hold. Metabolic images were fused and analyzed with CT images: the whole- body PET images with the non–ECG- gated whole- body NECT images first and then the gated cardiac PET with the cardiac CTA images. Data were interpreted by a group of experts in cardiac imaging (cardiologist, radiologist, and nuclear medicine specialist) who were blinded to echocardiography results and according to the following criteria. Metabolic Images. Visual Analysis. Visual analysis assessed a focal or heterogeneous increase in 1. F- FDG activity related to the prosthetic material or cardiac lesions, identified in both the attenuation- corrected and uncorrected images. Semiquantitative Analysis. The intensity of 1. F- FDG uptake was measured as the maximum standardized uptake value (SUVmax) in the abnormal area. To overcome bias related to individual differences in 1. F- FDG metabolism, the mean standardized uptake value was obtained in the blood pool (patient’s background activity). The prosthetic prosthetic material–to–background standardized uptake value ratio (SUVratio) was then calculated by dividing the prosthetic material SUVmax by the aortic blood mean standardized uptake value. CT and CTA Images. Cardiac lesions, including vegetations, perivalvular extension of the infection seen as abscesses and collections, pseudoaneurysms, fistulas, and coronary artery involvement,1. The specific definitions are included in the online- only Data Supplement. Evaluation of coronary artery disease was performed according to the quality of the CTA study. Peripheral Findings. Whole- body PET/CT images were carefully examined to detect embolic events, findings indicating diagnoses other than IE, and incidental neoplastic lesions. Studies were classified into 1 of the following groups: positive for active infection, an intense focal or heterogeneous hypermetabolic activity related to the prosthetic material or to cardiac lesions, if present; negative for active infection, absence of hypermetabolic activity in the prosthetic material or in cardiac lesions (noninfectious postoperative complications or lesions related to past and currently cured endocarditis); and doubtful cases, mild homogenous FDG uptake, particularly in patients who recently had surgery.
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January 2017
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