Clinical information determines the impact of transesophageal echocardiography on the diagnosis of infective endocarditis by the Duke criteria

doi:10.1067/mhj.2000.104762

American Heart Journal

Volume 139, Issue 6, June 2000, Pages 945-951

https://doi.org/10.1067/mhj.2000.104762 Get rights and content

Abstract

Background Although transesophageal echocardiography (TEE) is more sensitive than transthoracic echocardiography (TTE) in detecting echocardiographic evidence of infective endocarditis (IE), the impact of TEE on the clinical diagnosis of IE has not been clearly delineated. Methods and Results We studied 112 patients with 114 suspected episodes of IE over a 6-year period who underwent both TTE and TEE during their diagnostic evaluation. Using the results of these studies along with clinical and microbiologic data, we attempted to determine the incremental value of TEE to the Duke Endocarditis Diagnostic Criteria. Patients were initially classified into a diagnostic category of the Duke criteria with TTE data, and then the diagnostic classification was reconsidered with TEE data. A diagnostic category reassignment occurred in 25 of 114 episodes of IE evaluated when TEE results were incorporated into the evaluation with the Duke criteria (22 patients were reclassified from possible IE to definite IE whereas 3 patients were reclassified from rejected to possible IE). Diagnostic reclassification occurred in 9 (11%) of the 80 episodes of suspected IE with native cardiac valves and 13 (34%) of 34 episodes with prosthetic cardiac valves. Most patients reclassified from possible IE to definite IE with TEE data (19 of 22) had an intermediate clinical likelihood of IE, whereas 92% of patients had negative TTE results. Pathologic examination of valvular tissue in 22 of the 114 episodes of suspected IE revealed that the positive predictive value of the Duke criteria with TEE data for diagnosis of IE was 85% in patients with native valves and 89% in patients with prosthetic valves. Conclusions When clinical evidence of IE is present, TEE improves the sensitivity of the Duke criteria to diagnose definite IE. TEE data appears to be especially useful for the diagnostic evaluation of patients with suspected IE who have prosthetic valves. (Am Heart J 2000;139:945-51.)

Section snippets

Patient selection

An endocarditis database was established at Duke University Medical Center (DUMC) in October 1988 to include all patients with suspected IE evaluated at DUMC. The study population consisted of patients in the Duke endocarditis database from October 1988 to December 1995 who had at least one TTE and TEE examination performed within a 7-day period during their initial evaluation at DUMC. A total of 567 patients were in the database at the time this study was undertaken. Patients with recurrent

Patient characteristics

A total of 112 patients with 114 episodes of suspected IE underwent both TTE and TEE examinations during the study period. Native cardiac valves were present in 80 (70%) of the episodes of suspected IE, and 1 or more prosthetic cardiac valves was present in 34 (30%) of the episodes. A category reassignment occurred when TEE results were incorporated into the diagnostic evaluation with the Duke criteria in 25 of the 114 episodes evaluated. The remaining 89 episodes of suspected IE were

Discussion

By using a classification system based on the Duke criteria for IE and TTE findings, we found that TEE findings resulted in important changes in the diagnostic classification in almost 25% of the patients evaluated. Although only 11% of patients with native valves were reclassified to a new diagnostic category with TEE findings, 34% of patients with prosthetic valves were reclassified. The majority of patients who were reclassified to a new category were diagnosed with definite IE on the basis

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^☆: Guest Editor for this manuscript was William F. Armstrong, MD, University of Michigan, Ann Arbor.

^☆☆: Reprint requests: Matthew T. Roe, MD, Duke Clinical Research Institute, PO Box 17969, Durham, NC 27715. E-mail: [email protected]

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Progress in CardiologyClinical information determines the impact of transesophageal echocardiography on the diagnosis of infective endocarditis by the Duke criteria☆,☆☆

Abstract

Section snippets

Patient selection

Patient characteristics

Discussion

Cardiol Clin

Chest

Chest

Chest

J Am Coll Cardiol

Chest

Am Heart J

J Am Coll Cardiol

Am J Med

Am J Med

Cardiol Clin

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Soc Echocardiogr

Progress in Cardiology
Clinical information determines the impact of transesophageal echocardiography on the diagnosis of infective endocarditis by the Duke criteria☆,☆☆