Modern tools in cardiac imaging to assess myocardial inflammation and infection

Figures

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  Figure 1. Added value of transoesophageal echocardiogram after transthoracic echocardiogram showing high-risk features of infective endocarditis. A 76-year-old male was presented with Enterococcus faecalis bacteraemia after complicated urinary tract infection. Transthoracic echocardiogram showed large aortic valve vegetation (A, arrow) with severe aortic regurgitation (B). Given high-risk features, a transoesophageal echocardiogram was obtained demonstrating paravalvular abscess in the anterior aortic root (D, star) along with previously demonstrated large aortic valve vegetation with severe regurgitation (C and E). The patient underwent surgical aortic valve replacement with aortic root repair.

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  Figure 2. Complementary value of computed tomography in prosthetic infective endocarditis. A 35-year-old female with a history of Methicillin-resistant Staphylococcus aureus infective endocarditis status post-mitral valve replacement complicated by recurrent infective endocarditis requiring redo mitral valve replacement ×2, presented with heart failure symptoms. Transoesophageal echocardiogram showed paravalvular leak in the mitral position with possible abscess (arrow). Computed tomography angiography demonstrated large pseudoaneurysm in the anterolateral aspect of the valve (stars).

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  Figure 3. Role of positron emission tomography in prosthetic valve endocarditis. A 53-year-old female with a history of quadricuspid aortic valve and aortic valve replacement 3 years prior presented after episode of fever and chills, found to have Methycillin-sensitive Staphylococcus epidermidis bacteraemia. Transthoracic echocardiogram and transoesophageal echocardiogram did not reveal evidence of endocarditis but prosthetic leaflets were not well visualized due to prosthesis-related artefact. Positron emission tomography was obtained to assess for prosthetic valve endocarditis and revealed focal FDG uptake surrounding the replaced aortic valve. The patient underwent repeat aortic valve replacement. The surgically explanted valve had a large vegetation and pathology revealed granulation tissue with gram-positive cocci in clusters.

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  Figure 4. Transthoracic echocardiogram features in cardiac sarcoidosis. A 51-year-old male presenting with resuscitated cardiac arrest. Transthoracic echocardiogram revealed focal aneurysm in the mid inferoseptal wall (star). Later diagnostic work-up confirmed cardiac sarcoidosis.

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  Figure 5. A 58-year-old female was undergoing evaluation for cardiomyopathy in the setting of dyspnoea on exertion and non-sustained ventricular tachycardia. Cardiac magnetic resonance revealed increased signal at the basal to mid septum and inferior wall on T2 STIR imaging (A, arrow) consistent with active inflammation and LGE in these segments (B, arrow) in a non-ischaemic pattern consistent with cardiac sarcoidosis.

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  Figure 6. A 35-year-old female was undergoing evaluation for non-ischaemic cardiomyopathy. Initial positron emission tomography for evaluation of cardiac sarcoidosis was non-diagnostic due to failure to suppress myocardial FDG uptake (A). A second attempt using a ketogenic diet preparation revealed no evidence of active inflammation with FDG uptake limited to the cardiac blood pool (B). Note: upper panel corresponds to rest positron emission tomography myocardial perfusion imaging.

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  Figure 7. A 58-year-old female was presenting for evaluation of non-sustained ventricular tachycardia. Cardiac positron emission tomography for evaluation of cardiac sarcoidosis revealed large amount of inflamed myocardium (FDG uptake, downward facing arrows) with mismatch perfusion defect (upwards facing arrows) in the basal septum and basal inferoseptum. Whole-body positron emission tomography revealed fluorodeoxyglucose avid bilateral hilar and mediastinal lymph nodes concerning for active cardiac sarcoidosis.

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  Figure 8. Comparative utility of available imaging modalities to assess forms of myocardial infection.

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  Figure 9. Comparative utility of available imaging modalities to assess myocardial forms of inflammation.