18F-FDG PET/CT in Infective Endocarditis: Indications and Approaches for Standardization

Abstract Purpose of Review Additional imaging modalities, such as FDG-PET/CT, have been included into the workup for patients with suspected infective endocarditis, according to major international guidelines published in 2015. The purpose of this review is to give an overview of FDG-PET/CT indications and standardized approaches in the setting of suspected infective endocarditis. Recent Findings There are two main indications for performing FDG-PET/CT in patients with suspected infective endocarditis: (i) detecting intracardiac infections and (ii) detection of (clinically silent) disseminated infectious disease. The diagnostic performance of FDG-PET/CT for intracardiac lesions depends on the presence of native valves, prosthetic valves, or implanted cardiac devices, with a sensitivity that is poor for native valve endocarditis and cardiac device-related lead infections, but much better for prosthetic valve endocarditis and cardiac device-related pocket infections. Specificity is high for all these indications. The detection of disseminated disease may also help establish the diagnosis and/or impact patient management. Summary Based on current evidence, FDG-PET/CT should be considered for detection of disseminated disease in suspected endocarditis. Absence of intracardiac lesions on FDG-PET/CT cannot rule out native valve endocarditis, but positive findings strongly support the diagnosis. For prosthetic valve endocarditis, standard use of FDG-PET/CT is recommended because of its high sensitivity and specificity. For implanted cardiac devices, FDG-PET/CT is also recommended, but should be evaluated with careful attention to clinical context, because its sensitivity is high for pocket infections, but low for lead infections. In patients with prosthetic valves with or without additional aortic prosthesis, combination with CTA should be considered. Optimal timing of FDG-PET/CT is important, both during clinical workup and technically (i.e., post tracer injection). In addition, procedural standardization is key and encompasses patient preparation, scan acquisition, reconstruction, subsequent analysis, and clinical interpretation. The recommendations discussed here will hopefully contribute to improved standardization and enhanced performance of FDG-PET/CT in the clinical management of patients with suspected infective endocarditis.

Download Full-text

Nuclear Imaging in Infective Endocarditis

Pharmaceuticals ◽

10.3390/ph15010014 ◽

2021 ◽

Vol 15 (1) ◽

pp. 14

Author(s):

Nidaa Mikail ◽

Fabien Hyafil

Keyword(s):

Computed Tomography ◽

Infective Endocarditis ◽

Fdg Pet ◽

Imaging Techniques ◽

Nuclear Imaging ◽

Emission Tomography ◽

Cardiac Devices ◽

Pet Ct ◽

18F Fdg ◽

Fdg Pet Ct

Infective endocarditis (IE) is a life-threatening disease with stable prevalence despite prophylactic, diagnostic, and therapeutic advances. In parallel to the growing number of cardiac devices implanted, the number of patients developing IE on prosthetic valves and cardiac implanted electronic device (CIED) is increasing at a rapid pace. The diagnosis of IE is particularly challenging, and currently relies on the Duke-Li modified classification, which include clinical, microbiological, and imaging criteria. While echocardiography remains the first line imaging technique, especially in native valve endocarditis, the incremental value of two nuclear imaging techniques, 18F-fluorodeoxyglucose positron emission tomography with computed tomography (18F-FDG-PET/CT) and white blood cells single photon emission tomography with computed tomography (WBC-SPECT), has emerged for the management of prosthetic valve and CIED IE. In this review, we will summarize the procedures for image acquisition, discuss the role of 18F-FDG-PET/CT and WBC-SPECT imaging in different clinical situations of IE, and review the respective diagnostic performance of these nuclear imaging techniques and their integration into the diagnostic algorithm for patients with a suspicion of IE.

Download Full-text

The utility of 18F-fluorodeoxyglucose positron emission tomography with computed tomography in Mycobacterium chimaera endocarditis: a case series

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytz209 ◽

2019 ◽

Vol 3 (4) ◽

pp. 1-6 ◽

Cited By ~ 1

Author(s):

Mohamed Dafaalla ◽

Nicholas Weight ◽

Verran Cajic ◽

Uday Dandekar ◽

Kishore Gopalakrishnan ◽

...

Keyword(s):

Infective Endocarditis ◽

Fdg Pet ◽

Delayed Diagnosis ◽

Case Series ◽

Unknown Origin ◽

Ct Scanning ◽

Blood Cultures ◽

Prosthetic Valves ◽

Pet Ct ◽

Fdg Pet Ct

Abstract Background Infective endocarditis secondary to Mycobacterium chimaera can present with classical constitutional symptoms of infective endocarditis but can be blood culture negative and without vegetations on transthoracic or transoesophageal echocardiogram. Patients with prosthetic valves are at particularly high risk. Case summary We present two patients who were diagnosed with infective endocarditis secondary to M. chimaera infection. They presented similarly with pyrexia of unknown origin and night sweats. Both patients had previously undergone aortic valve replacement; one with a tissue valve and the other with a metallic valve. New cardiac murmurs were evident on auscultation, but clinical examination showed no peripheral stigmata of endocarditis. Transoesophageal echo and transthoracic echo were both unremarkable, as were serial blood cultures. FDG PET CT scan was the key investigation, which showed increased uptake in the spleen beside other areas. Histopathology and mycobacterial cultures confirmed the diagnosis of M. chimaera infection in both cases. The first patient completed medical therapy and is now fit and well. However, the second patient unfortunately developed disseminated infection causing death. Discussion The management of M. chimaera infective endocarditis is challenging, often with delayed diagnosis and poor outcomes. In the context of negative blood cultures and inconclusive echocardiograms where there remains a high index of suspicion for endocarditis, FDG PET CT scanning can be a crucial diagnostic importance and should be considered early in patients with prosthetic valves.

Download Full-text

Role of 18F-FDG PET/CT in the diagnosis of infective endocarditis in patients with an implanted cardiac device: a prospective study

European Journal of Nuclear Medicine and Molecular Imaging ◽

10.1007/s00259-014-2773-z ◽

2014 ◽

Vol 41 (8) ◽

pp. 1617-1623 ◽

Cited By ~ 54

Author(s):

Maddalena Graziosi ◽

Cristina Nanni ◽

Massimiliano Lorenzini ◽

Igor Diemberger ◽

Rachele Bonfiglioli ◽

...

Keyword(s):

Infective Endocarditis ◽

Prospective Study ◽

Fdg Pet ◽

Cardiac Device ◽

Pet Ct ◽

18F Fdg ◽

A Prospective Study ◽

Fdg Pet Ct

Download Full-text

The Diagnostic Value of 99mTc-HMPAO-Labelled White Blood Cell Scintigraphy and 18F-FDG PET/CT in Cardiac Device-Related Infective Endocarditis—A Systematic Review

Journal of Personalized Medicine ◽

10.3390/jpm11101016 ◽

2021 ◽

Vol 11 (10) ◽

pp. 1016

Author(s):

Katarzyna Holcman ◽

Paweł Rubiś ◽

Agnieszka Stępień ◽

Katarzyna Graczyk ◽

Piotr Podolec ◽

...

Keyword(s):

Infective Endocarditis ◽

Fdg Pet ◽

Diagnostic Value ◽

Emission Tomography ◽

Cardiac Device ◽

Hmpao Spect ◽

Pet Ct ◽

18F Fdg ◽

Fdg Pet Ct ◽

99Mtc Hmpao

(1) Background: Treatment of cardiac arrhythmias and conduction disorders with the implantation of a cardiac implantable electronic device (CIED) may lead to complications. Cardiac device-related infective endocarditis (CDRIE) stands out as being one of the most challenging in terms of its diagnosis and management. Developing molecular imaging modalities may provide additional insights into CDRIE diagnosis. (2) Methods: We performed a systematic literature review to critically appraise the evidence for the diagnostic performance of the following hybrid techniques: single photon emission tomography with technetium99m-hexamethylpropyleneamine oxime–labeled autologous leukocytes (99mTc-HMPAO-SPECT/CT) and positron emission tomography with fluorodeoxyglucose (18F-FDG PET/CT). An analysis was performed in accordance with PRISMA and GRADE criteria and included articles from PubMed, Embase and Cochrane databases. (3) Results: Initially, there were 2131 records identified which had been published between 1971–2021. Finally, 18 studies were included presenting original data on the diagnostic value of 99mTc-HMPAO-SPECT/CT or 18F-FDG PET/CT in CDRIE. Analysis showed that these molecular imaging modalities provide high diagnostic accuracy and their inclusion in diagnostic criteria improves CDRIE work-up. (4) Conclusions: 99mTc-HMPAO-SPECT/CT and 18F-FDG PET/CT provide high diagnostic value in the identification of patients at risk of CDRIE and should be considered for inclusion in the CDRIE diagnostic process.

Download Full-text

346[18F]FDG PET/CT in a non-valvular cardiac device infective endocarditis

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jez138.010 ◽

2019 ◽

Vol 20 (Supplement_3) ◽

Author(s):

P I D S Soeiro ◽

R Silva ◽

G Costa ◽

J Pedroso Lima ◽

M J Ferreira

Keyword(s):

Infective Endocarditis ◽

Fdg Pet ◽

Cardiac Device ◽

Pet Ct ◽

18F Fdg ◽

Fdg Pet Ct

Download Full-text

18F-FDG PET/CT improves diagnostic certainty in native and prosthetic valve Infective Endocarditis over the modified Duke Criteria

Journal of Nuclear Cardiology ◽

10.1007/s12350-021-02689-5 ◽

2021 ◽

Author(s):

Christopher P. Primus ◽

Thomas A Clay ◽

Maria S. McCue ◽

Kit Wong ◽

Rakesh Uppal ◽

...

Keyword(s):

Infective Endocarditis ◽

Fdg Pet ◽

Prosthetic Valve ◽

Standardized Uptake Value ◽

Prosthetic Valve Endocarditis ◽

Incremental Benefit ◽

Duke Criteria ◽

Diagnostic Certainty ◽

Pet Ct ◽

Fdg Pet Ct

Abstract Background International guidance recognizes the shortcomings of the modified Duke Criteria (mDC) in diagnosing infective endocarditis (IE) when transoesophageal echocardiography (TOE) is equivocal. 18F-FDG PET/CT (PET) has proven benefit in prosthetic valve endocarditis (PVE), but is restricted to extracardiac manifestations in native disease (NVE). We investigated the incremental benefit of PET over the mDC in NVE. Methods Dual-center retrospective study (2010-2018) of patients undergoing myocardial suppression PET for NVE and PVE. Cases were classified by mDC pre- and post-PET, and evaluated against discharge diagnosis. Receiver Operating Characteristic (ROC) analysis and net reclassification index (NRI) assessed diagnostic performance. Valve standardized uptake value (SUV) was recorded. Results 69/88 PET studies were evaluated across 668 patients. At discharge, 20/32 had confirmed NVE, 22/37 PVE, and 19/69 patients required surgery. PET accurately re-classified patients from possible, to definite or rejected (NRI: NVE 0.89; PVE 0.90), with significant incremental benefit in both NVE (AUC 0.883 vs 0.750) and PVE (0.877 vs 0.633). Sensitivity and specificity were 75% and 92% in NVE; 87% and 86% in PVE. Duration of antibiotics and C-reactive Protein level did not impact performance. No diagnostic SUV cut-off was identified. Conclusion PET improves diagnostic certainty when combined with mDC in NVE and PVE.

Download Full-text

18F-fluorodeoxyglucose positron emission tomography computed tomography (18F-PET/CT) for the diagnosis of native valve infective endocarditis (NVIE): a prospective study

European Heart Journal ◽

10.1093/ehjci/ehaa946.2024 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

M Philip ◽

S Delcourt ◽

S Cammilleri ◽

F Gourriet ◽

L Tessonnier ◽

...

Keyword(s):

Infective Endocarditis ◽

Fdg Pet ◽

Final Diagnosis ◽

Native Valve ◽

Positron Emission ◽

Pet Ct ◽

Splenic Uptake ◽

Major Criterion ◽

18F Fdg ◽

Fdg Pet Ct

Abstract Background and objectives 18F-FDG PET/CT has recently been added as a major criterion in the ESC 2015 infective endocarditis (IE) guidelines. We and others have demonstrated that18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) / computed tomography (CT) was useful in patients with suspected prosthetic valve and cardiac device IE. However, the sensitivity and specificity of ESC classification is unknown in patients with native valve endocarditis (NVE) as well as the clinical impact of PET findings. Purposes 1. Primary objective: To assess the value of the new ESC criteria including 18F-FDG PET/CT in native valve infective endocarditis (NVIE). 2. Secondary objectives: – to determine the usefulness of PET/CT concerning embolic or neoplastic detection. – to describe a new PET/CT feature, i.e. the diffuse splenic uptake. Methods Between 2012 and 2017, 75 patients with suspected NVIE were prospectively included, after exclusion of patients with uninterpretable or not feasible PET/CT. Using the expert consensus of the Endocarditis Team after a 3-month follow-up as gold standard, 63 IE were confirmed and 12 were rejected. Patients follow-up was scheduled at one and three months after hospitalization. Results Significant cardiac uptake by PET/CT (major criterion) was observed in 11 among 63 patients with definite NVIE and no patients with rejected IE (sensitivity 18%, specificity 100%). Among the 63 patients with a final diagnosis of NVE, a peripheral embolism or mycotic aneurysm was observed in 20 cases (32%). Considering this, the ESC 2015 classification increased the sensitivity of Duke criteria from 64 to 70% (p<0.001) without no change on specificity (p<0.001). Twenty-four patients (38%) were diagnosed with secondary infectious sites or infectious portal of entry. A diffuse splenic uptake was observed in 39 (52%) patients, including 37 (59%) of patients with a final diagnosis of NVE (specificity 83%). Conclusion 1. The value of 18F-FDG PET/CT in NVE diagnosis is poor (18% sensitivity) 2. Usefulness of PET/CT remains high when concerning embolic or neoplastic detection. 3. Our study describes for the first time in NVE a new potential endocarditis criterion, i.e. the presence of a diffuse splenic uptake on 18F-FDG PET/CT Diffuse splenic uptake Funding Acknowledgement Type of funding source: None

Download Full-text

Challenging case of chronic Q fever endocarditis: usefulness of 18F-FDG PET/CT in the diagnosis and follow-up

BMJ Case Reports ◽

10.1136/bcr-2021-243290 ◽

2021 ◽

Vol 14 (8) ◽

pp. e243290

Author(s):

Anna Hermine Markowich ◽

Lorenza Romani ◽

Lucia Leccisotti ◽

Maia De Luca

Keyword(s):

Fdg Pet ◽

Q Fever ◽

Specific Treatment ◽

Prosthetic Valve Endocarditis ◽

Serological Tests ◽

Prosthetic Valves ◽

Chronic Q Fever ◽

Pet Ct ◽

Fdg Pet Ct

Diagnosis of infective endocarditis can be challenging for clinicians, especially when involving prosthetic valves. Recent data suggest that 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) could be a useful diagnostic tool in this setting. Here, we report a case of a patient with an aortic biological prosthesis who presented with a history of fever and fatigue. Echocardiograms were negative for vegetations. The 18F-FDG PET/CT revealed an infective process of the valve and serological tests were positive for chronic Coxiella burnetii infection. Specific treatment for chronic Q fever endocarditis was, therefore, started and the response was monitored using 18F-FDG PET/CT. This case highlights the challenges and pitfalls clinicians face when confronted with prosthetic valve endocarditis and the use of 18F-FDG PET/CT for diagnosis and follow-up.

Download Full-text