The Role of the 18F-FDG PET/CT in the Management of Patients Suspected of Cardiac Implantable Electronic Devices’ Infection

Figures

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  Figure 1. Procedural recommendations and dietary preparation for myocardial glucose metabolism suppression preliminary to 18F-FDG PET/CT execution.

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  Figure 2. A graphic representation of the microbiological analysis results from blood cultures.

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  Figure 3. 18F-FDG PET/CT of a 64-year-old man with implanted biventricular ICD, with suspected CIEDI due to alteration of inflammation indices, despite negative blood culture. The MIP projection shows the absence of areas of increased 18F-FDG uptake attributable to infection both in correspondence with the pocket and along the course of the leads.

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  Figure 4. 18F-FDG PET/CT of a 73-year-old man with implanted ICD, with suspected CIEDI due to the presence of local signs of infection and positive blood culture for Staphylococcus aureus. (A) MIP, (B) axial PET and (C) axial fusion images demonstrate the presence of intense and nonhomogeneous increased 18F-FDG uptake around the device, at the generator pocket (SUVmax 12.9) (red arrows). After the extraction of the device, microbiological analysis confirmed the infection caused by the pathogen Staphylococcus aureus.

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  Figure 5. 18F-FDG PET/CT of a 35-year-old man with implanted ICD, with suspected CIEDI due to persistent alteration of inflammation indices and positive blood culture for Staphylococcus epidermidis, in the absence of fever and local signs of infection. The (A) MIP, (B,D) axial fusion and (C,E) coronal fusion images demonstrate the presence of areas of intense and focal increased 18F-FDG uptake along the lead pathway, both at the retroclavicular level (SUVmax 6.4) (red arrows) and at the intrathoracic level (SUVmax 15.6) (blue arrows). The microbiological analysis, following the extraction of the device, confirmed the infection sustained by the pathogen Staphylococcus epidermidis.

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  Figure 6. 18F-FDG PET/CT of a 48-year-old man with implanted PM, with suspected CIEDI for therapy-resistant hyperpyrexia and positive blood culture for Pseudomonas aeruginosa. (A) MIP, (B) axial PET, (C) axial fusion, (D) coronal fusion, and (E) sagittal fusion images demonstrate the presence of intense hyperaccumulation of 18F-FDG along the pericardial part of the lead (SUVmax 25.5) (red arrows). The patient underwent extraction of the device and microbiological analysis confirmed the bacterial infection.

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  Figure 7. 18F-FDG PET/CT of a 66-year-old man with a dual-chamber ICD with suspected CIEDI. (A) MIP, (B) axial PET, (C) axial fusion, (D) coronal fusion, and (E) sagittal fusion images demonstrate widespread glucose uptake throughout the myocardium, indicative of poor adherence to the dietary protocol for myocardial suppression; these images are considered of poor quality. The 18F-FDG PET/CT was considered negative for CIEDI but it was revealed to be a false negative.

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  Figure 8. Graphic representation of the microbiological analysis results from the removed material.

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  Figure 9. ROC curves of the following semi-quantitative parameters: SUVmax; SQR; TBR.

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  Figure 10. A graphic representation of the trend over time of the degree of adherence to the myocardial suppression dietary protocol.