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Multicenter Study
. 2021 Oct;28(5):2072-2082.
doi: 10.1007/s12350-019-01963-x. Epub 2019 Dec 2.

Added value of 18F-FDG-PET/CT and cardiac CTA in suspected transcatheter aortic valve endocarditis

Ali R Wahadat #  1   2   3   4 , Wilco Tanis #  5 , Laurens E Swart  6   7 , Asbjørn Scholtens  8 , Gabriel P Krestin  6 , Nicolas M D A van Mieghem  7 , Carolina A M Schurink  9   10 , Tycho I G van der Spoel  5   11 , Floris S van den Brink  12   13 , Tessel Vossenberg  13 , Riemer H J A Slart  14 , Andor W J M Glaudemans  14 , Jolien W Roos-Hesselink  7 , Ricardo P J Budde  6   7
Affiliations
Multicenter Study

Added value of 18F-FDG-PET/CT and cardiac CTA in suspected transcatheter aortic valve endocarditis

Ali R Wahadat et al. J Nucl Cardiol. 2021 Oct.

Abstract

Backgrounds: Transcatheter-implanted aortic valve infective endocarditis (TAVI-IE) is difficult to diagnose when relying on the Duke Criteria. Our aim was to assess the additional diagnostic value of 18F-fluorodeoxyglucose (18F-FDG) positron emission/computed tomography (PET/CT) and cardiac computed tomography angiography (CTA) in suspected TAVI-IE.

Methods: A multicenter retrospective analysis was performed in all patients who underwent 18F-FDG-PET/CT and/or CTA with suspected TAVI-IE. Patients were first classified with Duke Criteria and after adding 18F-FDG-PET/CT and CTA, they were classified with European Society of Cardiology (ESC) criteria. The final diagnosis was determined by our Endocarditis Team based on ESC guideline recommendations.

Results: Thirty patients with suspected TAVI-IE were included. 18F-FDG-PET/CT was performed in all patients and Cardiac CTA in 14/30. Using the Modified Duke Criteria, patients were classified as 3% rejected (1/30), 73% possible (22/30), and 23% definite (7/30) TAVI-IE. Adding 18F-FDG-PET/CT and CTA supported the reclassification of 10 of the 22 possible cases as "definite TAVI-IE" (5/22) or "rejected TAVI-IE" (5/22). This changed the final diagnosis to 20% rejected (6/30), 40% possible (12/30), and 40% definite (12/30) TAVI-IE.

Conclusions: Addition of 18F-FDG-PET/CT and/or CTA changed the final diagnosis in 33% of patients and proved to be a valuable diagnostic tool in patients with suspected TAVI-IE.

Keywords: CT; Infection; PET; valvular heart disease.

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Figures

Figure 1
Figure 1
Distribution of patients with suspected Endocarditis based on Modified Duke Criteria, ESC criteria, and Endocarditis Team consensus based on ESC criteria
Figure 2
Figure 2
Positive results of either TTE/TEE, FDG-PET, and Cardiac CTA in each group with final diagnosis of rejected, possible, and definite TAVI-IE
Figure 3
Figure 3
Two cases of one positive PET/CT and one negative PET/CT for TAVI-IE. Case 1 (A to E): A 75-year-old female with suspected Corevalve TAVI-IE who underwent a TEE without signs of endocarditis (A to C). PET/CT images (D/E) demonstrated focal FDG uptake alongside the corevalve as positive sign of TAVI-IE. This case was previously published as a case report. Case 2 (F to I): An 81-year-old female with suspected Edwards-Sapien TAVI-IE who underwent a TEE (F/G) with a vegetation on the aortic valve and mild aortic regurgitation. CTA demonstrated thickening of the aortic valve leaflets (H) as possible signs of vegetation. However, PET/CT images (I) showed no focal 18F-FDG uptake on the leaflets. This was explained by the low inflammatory activity and 2 weeks of intravenous antibiotic therapy prior to the PET/CT scan
Figure 4
Figure 4
CTA images of a 77-year-old male with suspected TAVI-IE. Initial TEE (A, B) showed only thickened aortic valve leaflets as signs of vegetation. Repeating TEE after a few days (C, D) showed a new aortic regurgitation and a paravalvular space as sign of possible mycotic aneurysm, which was confirmed on the CTA (E)
Figure 5
Figure 5
CTA images of a Sapiens valve with signs of leaflet thrombosis (A, C, E) and a Lotus valve with signs of vegetation (B, D, F)
See this image and copyright information in PMC

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