Improvement in the Diagnosis of Abscesses Associated with Endocarditis by Transesophageal Echocardiography

TLDR

Echocardiography is the preferred noninvasive method for detecting valvular vegetations in infective endocarditis, with transesophageal echocardiography being more accurate than transthoracic echocardiography, and abscesses are more common in aortic valve infections and more often caused by Staphylococcus. To determine whether transesophageal echocardiography improves detection of abscesses associated with endocarditis compared to transthoracic echocardiography, the authors prospectively studied 118 patients with infective endocarditis. Transesophageal echocardiography detected 40 of 46 abscesses (sensitivity 87.0 %, specificity 94.6 %) versus 13 detected by transthoracic echocardiography (sensitivity 28.3 %, specificity 98.6 %), leading to a significant improvement in abscess diagnosis, higher mortality in abscess patients (22.7 % vs 13.5 %), and earlier identification of high‑risk patients.

Abstract

Echocardiography is recognized as the method of choice for the noninvasive detection of valvular vegetations in patients with infective endocarditis, with transesophageal echocardiography being more accurate than transthoracic echocardiography. The diagnosis of associated abscesses by transthoracic echocardiography is difficult or even impossible in many cases, however, and it is not known whether transesophageal echocardiography is any better.To determine the value of transesophageal echocardiography in the detection of abscesses associated with endocarditis, we studied prospectively by two-dimensional transthoracic and transesophageal echocardiography 118 consecutive patients with infective endocarditis of 137 native or prosthetic valves that was documented during surgery or at autopsy.During surgery or at autopsy, 44 patients (37.3 percent) had a total of 46 definite regions of abscess. Abscesses were more frequent in aortic-valve endocarditis than in infections of other valves, and the infecting organism was more often staphylococcus (52.3 percent of cases) in patients with abscesses than in those without abscesses (16.2 percent). The hospital mortality rate was 22.7 percent in patients with abscesses, as compared with 13.5 percent in patients without abscesses. Whereas transthoracic echocardiography identified only 13 of the 46 areas of abscess, the transesophageal approach allowed the detection of 40 regions (P less than 0.001). Sensitivity and specificity for the detection of abscesses associated with endocarditis were 28.3 and 98.6 percent, respectively, for transthoracic echocardiography and 87.0 and 94.6 percent for transesophageal echocardiography; positive and negative predictive values were 92.9 and 68.9 percent, respectively, for the transthoracic approach and 90.9 and 92.1 percent for the transesophageal approach. Variation between observers was 3.4 percent for transthoracic and 4.2 percent for transesophageal echocardiography.The data indicate that transesophageal echocardiography leads to a significant improvement in the diagnosis of abscesses associated with endocarditis. The technique facilitates the identification of patients with endocarditis who have an increased risk of death and permits earlier treatment.