Diagnostic Value of Computed Tomography Angiography for Infective Endocarditis After Right Ventricle Outflow Tract Repair

Q: What is the clinical evidence from this study?

Study design: Observational. Population: Congenital heart disease with pulmonary valve infective endocarditis (n=6). Intervention: Functional cardiac computed tomography angiography (CTA) vs. Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE). Primary outcome: Definitive visualization of pulmonary valve or conduit abnormalities/vegetations and pulmonary complications to aid in infective endocarditis diagnosis.

Q: What does this research mean for the field?

Functional cardiac computed tomography angiography aids in the definitive diagnosis of pulmonary valve infective endocarditis and detection of associated pulmonary complications in congenital heart disease patients after right ventricular outflow tract repair. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Christina Thaler; Dawn Witt; Susan A. Casey; Angela M. Kelle; Santiago García; John Lesser; Bo Han

doi:10.1016/j.jaccas.2023.102011

August 30, 2023JACC Case ReportsOpen Access

Diagnostic Value of Computed Tomography Angiography for Infective Endocarditis After Right Ventricle Outflow Tract Repair

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Key result

Cardiac CTA identifies pulmonary valve infective endocarditis in ~100% of cases vs. ~17% with TTE.

n=6

Figures

Graphical abstract published by JACC Case Reports — Graphical abstract · Published by JACC Case Reports · CC BY-NC-ND

Why the study?

Congenital heart disease patients with pulmonary valve replacement or right ventricle–pulmonary artery conduit have an increased risk of pulmonary valve endocarditis.

Does functional cardiac computed tomography angiography aid in the visualization of valve vegetations and pulmonary complications for diagnosing infective endocarditis in congenital heart disease patients with prior RVOT repair?

Key Points

To evaluate the diagnostic utility of cardiac computed tomography angiography for visualizing pulmonary valve vegetations and perivalvular complications in patients with congenital heart disease.
Evaluated 6 consecutive patients with congenital heart disease aged 16 to 40 years with surgical right ventricle-to-pulmonary artery homografts and suspected infective endocarditis.
Conducted transthoracic echocardiography in all 6 patients, transesophageal echocardiography in 1 patient, and cardiac computed tomography angiography in all 6 patients.
Transthoracic echocardiography detected valvar vegetation in 1 patient and functional pulmonary valve changes in 5 patients, while transesophageal echocardiography in 1 patient was non-diagnostic due to artifacts.
Cardiac computed tomography angiography identified valve leaflet thickening or mobile low-attenuation material across all 6 patients, definitive vegetations in 2 patients, and graft wall thickening concerning for abscess in 1 patient.
Computed tomography angiography identified pulmonary complications in 5 of 6 patients, detecting septic pulmonary emboli in 3 patients, pulmonary infarct in 1 patient, and septic pulmonary nodules in 3 patients.

Study Design

Type

Observational (n=6)

Multicenter

Yes

Structured PICO

Does functional cardiac computed tomography angiography aid in the visualization of valve vegetations and pulmonary complications for diagnosing infective endocarditis in congenital heart disease patients with prior RVOT repair?

P

Population

6 adult and pediatric congenital heart disease patients (aged 16 to 40 years) with prior surgical RV-to-PA homografts and pulmonary valve infective endocarditis at two US hospitals.

E

Exposure

Functional cardiac computed tomography angiography (CTA) using retrospectively triggered spiral scan with ECG gating, pulse modulation, dual-phase contrast injection for biventricular opacification, and prospectively ECG-triggered high-pitch helical scan for lung fields on a second- or third-generation Dual Source Scanner.

C

Comparator

Transthoracic echocardiography (TTE; performed in all 6 patients) and transesophageal echocardiography (TEE; performed in 1 patient).

O

Outcome

Visualization of pulmonary valve/conduit vegetations, leaflet thickening/prolapse, paravalvular abscess, and pulmonary sequelae (septic pulmonary emboli, infarcts, and nodules) to aid in diagnosis of infective endocarditis.surrogate

Main Result

Absolute Event Rate: 100% vs 16.7%

Functional cardiac CTA effectively overcomes echocardiographic artifact limitations in patients with prior RVOT conduits or prosthetic pulmonary valves to definitively visualize vegetations and detect septic pulmonary complications in suspected infective endocarditis.

Limitations

TEE was obtained in only 1 patient due to local practice patterns
Small case series sample size (n=6)
In patients with high levels of metallic artifacts, subtle valvar abnormalities or small vegetations could be missed
TEE was obtained in only 1 patient because local practice is to use CTA in this setting
Small sample size (6-patient case series)

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Implication

CTA may enhance pulmonary valve vegetation detection when TTE is limited; leaves open its diagnostic role pending prospective validation.

Abstract

Congenital heart disease patients with pulmonary valve replacement or right ventricle–pulmonary artery conduit have increased risk of pulmonary valve endocarditis. We present a 6-patient case series illustrating the diagnostic utility of computed tomography angiography to provide definitive visualization of pulmonary valve vegetation to aid in the diagnosis of endocarditis. (Level of Difficulty: Intermediate.)

Discussion

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Cite This Study

Thaler et al. (2023) conducted an observational in Congenital heart disease with pulmonary valve infective endocarditis (n=6). Functional cardiac computed tomography angiography (CTA) vs. Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) was evaluated on Definitive visualization of pulmonary valve or conduit abnormalities/vegetations and pulmonary complications to aid in infective endocarditis diagnosis. Functional cardiac CTA aided in diagnosing pulmonary valve infective endocarditis in 6 of 6 patients and identified pulmonary complications in 5 of 6, whereas TTE visualized vegetation in 1 of 6.

synapsesocial.com/papers/6a89aa39b4e829b19bd458c2 https://doi.org/10.1016/j.jaccas.2023.102011

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Diagnostic Value of Computed Tomography Angiography for Infective Endocarditis After Right Ventricle Outflow Tract Repair

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Diagnostic Value of Computed Tomography Angiography for Infective Endocarditis After Right Ventricle Outflow Tract Repair

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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