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18F-fluorodeoxyglucose positron-emission/computed tomography and cardiac computed tomography angiography as a diagnostic tool for suspected transcatheter aortic valve implantation endocarditis

Session Poster session 3

Speaker Ali Reza Wahadat

Event : EuroEcho 2018

  • Topic : imaging
  • Sub-topic : Imaging: Valve Disease
  • Session type : Poster Session

Authors : LE Swart (Rotterdam,NL), AR Wahadat (Rotterdam,NL), W Tanis (The Hague,NL), A Scholtens (Utrecht,NL), NMDA Van Mieghem (Rotterdam,NL), CAM Schurink (Rotterdam,NL), GP Krestin (Rotterdam,NL), JW Roos-Hesselink (Rotterdam,NL), RPJ Budde (Rotterdam,NL)

LE Swart1 , AR Wahadat1 , W Tanis2 , A Scholtens3 , NMDA Van Mieghem1 , CAM Schurink4 , GP Krestin5 , JW Roos-Hesselink1 , RPJ Budde5 , 1Erasmus Medical Center, Cardiology - Rotterdam - Netherlands , 2Haga University Hospital, Cardiology - The Hague - Netherlands , 3University Medical Center Utrecht, Nuclear Medicine - Utrecht - Netherlands , 4Erasmus Medical Center, Internal medicine - Rotterdam - Netherlands , 5Erasmus Medical Center, Radiology - Rotterdam - Netherlands ,

European Heart Journal - Cardiovascular Imaging ( 2019 ) 20 ( Supplement 1 ), i692

Introduction: Transcatheter aortic valve implantation (TAVI) endocarditis is a major complication after TAVI that is difficult to diagnose and relies on the Duke criteria comprising echocardiography and blood cultures.

Purpose: To assess the utility of 18F-fluorodeoxyglucose (18F-FDG) positron-emission/computed tomography (PET/CT) and cardiac computed tomography angiography (CTA) on top of echocardiography and blood cultures and to present the imaging findings in patients with suspected TAVI endocarditis.

Methods: From our institutional endocarditis database, all patients suspected of TAVI endocarditis were selected who underwent 18F-FDG PET/CT and/or cardiac CTA. PET/CT and CTA images were assessed in clinical practice by a nuclear medicine physician and cardiovascular radiologist respectively, while additional quantitative PET/CT analyses were performed by a nuclear medicine physician blinded to all clinical data. The maximum standardized uptake value (SUVmax) was measured in an automated VOI with a 40% isocontour around the valve on EARL-accredited reconstructions (where available), while the SUVratio was calculated as the ratio of the SUVmax and the mean SUV in the blood pool of the descending aorta. The final diagnosis of TAVI endocarditis was determined by our Endocarditis Team based on European Society of Cardiology guideline recommendations.

Results: A total of 14 patients (age 76±13 years; 6 males) were identified, including 10 with a final diagnosis of TAVI endocarditis. In 7/14 patients the implantation date was less than 3 months before the PET/CT scan. The median time since valve implantation was 106 days [0-1888]. PET/CT was performed in 13/14 patients and CTA in 11/14. Overall, 8/10 patients (80%) with a final diagnosis of TAVI endocarditis had signs of endocarditis on either the PET/CT (n=8) and/or CTA scans (n=5). Four patients were newly diagnosed based on visually abnormal uptake around the valve on PET/CT (n=3) and/or a vegetation on CTA (n=2), as echocardiography was only positive for signs of TAVI endocarditis in 4/10 (40%) patients. In 3/4 patients (75%) with an alternative diagnosis (central/peripheral line infections or pneumonia), the diagnosis of TAVI endocarditis was rejected based on the PET/CT. The average EARL SUVmax and SUVratio in the patients with endocarditis were 4.22±1.82 (range 2.66-8.00) and 2.20±0.81 (range 1.52-3.94), respectively. In patients without endocarditis, these averages were 3.52±0.43 (range 3.27-4.01; p=0.54) and 1.73±0.41 (range 1.31-2.13; p=0.36), respectively. Vegetations were the most common type of abnormality on the CTA (n=4) followed by mycotic aneurysms (n=2). No abscesses, valve dehiscence or other signs of endocarditis were seen on the CTA.

Conclusion: PET/CT and cardiac CTA are of additional value in the diagnosis of TAVI related endocarditis. Further research is required for refining the optimal diagnostic work flow of patients with suspected TAVI endocarditis.

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