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IMAGING VIGNETTE

Diagnosis of Infective EndocarditisAfter TAVRValue of a Multimodality Imaging Approach

Erwan Salaun, MD,a,b,c Laura Sportouch, MD,a Pierre-Antoine Barral, MD,b,d Sandrine Hubert, MD,a

Cécile Lavoute, PHD,a Anne-Claire Casalta, MD,a Julie Pradier, MD,a Daniel Ouk, MD,e Jean-Paul Casalta, MD,c

Marc Lambert, MD,a Frédérique Gouriet, MD, PHD,c Jean-Yves Gaubert, MD,d Aurélie Dehaene, MD,d

Alexis Jacquier, MD, PHD,b,d Laetitia Tessonnier, MD,e Julie Haentjens, PHD,a Alexis Theron, MD,f Alberto Riberi, MD,f

Serge Cammilleri, MD, PHD,e Dominique Grisoli, MD,f Nicolas Jaussaud, MD,f Frédéric Collart, MD,f

Jean-Louis Bonnet, MD,a Laurence Camoin, PHARD, PHD,c Sebastien Renard, MD,a Thomas Cuisset, MD, PHD,a

Jean-François Avierinos, MD, PHD,a Hubert Lepidi, MD,c Olivier Mundler, MD, PHD,e Didier Raoult, MD, PHD,c

Gilbert Habib, MDa,c

DIAGNOSIS OF INFECTIVE ENDOCARDITIS (IE) AFTER TRANSCATHETER AORTIC VALVE REPLACEMENT

(TAVR) remains difficult to establish using modified Duke criteria. We present the value of multi-imagingapproach (European Society of Cardiology [ESC]-2015 modified criteria) (1) in 16 patients referred for TAVR-IE suspicion (Figures 1 to 4, Online Tables 1 and 2). The final diagnosis defined by an expert-team at3 months of follow-up was definite-IE in 10, possible-IE in 1, and rejected-IE in 5. Echocardiography (n ¼ 16)revealed major criteria in 5 patients (5 vegetations, 2 paravalvular lesions) (Online Table 3) and new regurgi-tation in only 1 of them (Online Figure 1). Leaflet thickening and increased mean gradient were observedrespectively in 70% and 80% of definite-IE. Multislice computed tomography (CT) (n ¼ 11) identified majorcriteria in 2 patients (1 abscess, 1 pseudoaneurysm, and 1 fistulae), but evidenced vegetation and leafletthickening in 3 and 5 patients, respectively (Online Table 3). 18F-fluorodeoxyglucose positron-emissiontomography/CT (n ¼ 15) was positive in 9, and 18F-fluorodeoxyglucose uptake on transcatheter heart valvewas observed in all patients with definite-IE, except 1 (Online Table 6).

Comparing the classification on admission and the final diagnosis, the multi-imaging approach (ESC-2015modified criteria) presented with a higher diagnostic value (sensitivity ¼ 100% for definite-IE diagnosis,k ¼ 0.66 for all classes) than the modified Duke criteria (sensitivity ¼ 50%, k ¼ 0.21) (Online Figure 1, OnlineTables 4 and 5).

To conclude, in TAVR-IE: 1) atypical lesions of leaflets thickening and high transvalvular gradient(obstructive pattern) are frequent; and 2) conventional modified Duke criteria have a low diagnostic value;while multi-imaging approach (ESC-2015 modified criteria) have an excellent sensitivity in this setting, thanksto the use of multimodality imaging (Online Figure 2).

From the aCardiology Department, Assistance Publique Hôpitaux de Marseille (APHM)-La Timone Hospital, Marseille, France;bCentre de Résonance Magnétique Biologique et Médicale UMR 7339, Centre National de la Recherche Scientifique,

Aix-Marseille Université, Marseille, France; cUnité de Recherche sur les Maladies Infectieuses et Tropicales Emergentes,

Aix-Marseille Université—UM63, Centre National de la Recherche Scientifique 7278, IRD 198, Institut National de la Santé et de

la Recherche Médicale 1095-IHU—Méditerranée Infection, Marseille, France; dDepartment of Radiology and Cardiovascular

Imaging, APHM-La Timone Hospital, Marseille, France; eService Central de Biophysique et Médecine Nucléaire, APHM-La

Timone Hospital, Marseille, France; and the fCardiac Surgery Department, APHM-La Timone Hospital, Marseille, France.

The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Manuscript received March 7, 2017; revised manuscript received May 13, 2017, accepted May 18, 2017.

FIGURE 1 Obstructive Pattern in TAVR-IE

21 days later

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A 51-year-old man was admitted for a suspected–infective endocarditis (IE) 30 months after a transcatheter aortic valve replacement (TAVR) procedure with a 23-mm

first-generation Edwards Sapien transcatheter heart valve (Edwards Lifesciences, Irvine, California). Streptococcus bovis was identified in blood cultures. First

echocardiography only showed leaflets thickening (white arrows in A), highly turbulent jet in color Doppler (B), and high transvalvular mean gradient (27 mm Hg) (C).

IE was possible according to the modified Duke criteria; however, positron-emission tomography/computed tomography showed 18F-fluorodeoxyglucose uptake on

the transcatheter heart valve and thus IE was definite according to the multi-imaging criteria (European Society of Cardiology 2015 modified criteria). Initial adapted

antibiotic treatment was started. Repeated transesophageal echocardiography 3 weeks later found a large vegetation (red arrow in D and E), persistent leaflets

thickening (white arrow in D and E), highly turbulent jet (F), and without significant regurgitation (E). The Endocarditis team decided to perform a surgical aortic valve

replacement with a bioprosthesis, without post-operative complication and no relapse during the 3 years of follow-up. AO ¼ aorta; LA ¼ left atrium; LV ¼ left

ventricle.

FIGURE 2 Value of Multi-Imaging Approach in Doubtful Case of TAVR-IE

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IE was suspected in an 80-year-old man with S. anginosus found in blood cultures, 8 months after 29-mm Edwards Sapien 3 implantation. Transesophageal echo-

cardiography showed only leaflet thickening (white arrow in A and B) with moderate obstruction (C) (transvalvular mean gradient ¼ 20 mm Hg). At the admission, IE

was possible according to the modified Duke criteria. To complete the multi-imaging assessment, multislice computed tomography was performed and confirmed the

abnormal leaflet thickening (white arrow in D and E), positron-emission tomography/computed tomography showed a 18F-fluorodeoxyglucose uptake (F) on the

transcatheter heart valve and an infective metastatic localization (lumbar spondylodiscitis). Thus the multi-imaging approach (European Society of Cardiology 2015

modified criteria) at admission was in agreement with the final diagnosis of definite-IE at the end of follow-up. Abbreviations as in Figure 1.

Salaun et al. J A C C : C A R D I O V A S C U L A R I M A G I N G , V O L . 1 1 , N O . 1 , 2 0 1 8

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FIGURE 3 Value of Multislice CT and PET/CT in Definite-IE

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(A) An 83-year-old man with S. salivarus definite-IE 6 months after 26-mm Edwards Sapien 3 implantation. Transesophageal echocardiography (TEE) showed a large

vegetation (red arrow in a) and leaflets thickening (white arrows in b) with moderate obstruction (transvalvular mean gradient ¼ 20 mm Hg and high turbulent

jet [c]). Multislice computed tomography (CT) (d) confirmed the leaflet thickening at the upper level of the transcatheter heart valve (THV) and the vegetation at the

lower levels and found asymptomatic cerebral embolism and minor cerebral meningeal hemorrhage. Positron-emission tomography (PET)/CT showed the THV18F-fluorodeoxyglucose (18F-FDG) uptake (e). (B) An 80-year-old woman with S. aureus definite-IE 17 months after 23-mm Edwards Sapien XT implantation. TEE (a)

and transthoracic echocardiography (b) showed a mobile vegetation with only a trivial central regurgitation (c, d). Interpretation of multislice CT (e) was difficult

because of stent-related artifacts (white arrows); however, step-by-step levels examination confirmed the presence of vegetation (red arrows) at the lower levels.

Cerebral embolism was also seen in the multislice CT. PET/CT showed the THV 18F-FDG-uptake (f). (C) An 84-year-old man with Enterococcus faecalis definite-IE

8 months after 26-mm Edwards Sapien 3 implantation. TEE showed an abscess on the external aortic trigon (white arrows in a, b, and c)with a pseudo-aneurysm near

the THV stent (blue arrow in c) and a critical internal aortic periannular lesion with an aorto-right atrial fistulae (red arrows in a and b). Multislice CT confirmed all the

cardiac lesions in d, e, and f and showed a splenic lesion. PET/CT showed the THV 18F-FDG-uptake (g) and found a splenic 18F-FDG uptake that confirmed a splenic abscess

and a scrotal lesion with 18F-FDG-uptake, which was probably the predisposing infected lesion. PA ¼ pulmonary artery; other abbreviations as in Figures 1 and 2.

J A C C : C A R D I O V A S C U L A R I M A G I N G , V O L . 1 1 , N O . 1 , 2 0 1 8 Salaun et al.J A N U A R Y 2 0 1 8 : 1 4 3 – 6 Diagnosis of Infective Endocarditis After TAVR

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FIGURE 4 Remaining Doubtful Diagnosis and Possible TAVR-IE Despite Multimodality Approach

A CLA

LA LA

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FDB

A 70-year-old womanwas referred for persistent fever 3 months after 26-mm Edwards Sapien 3 implantation despite first line ambulatory antibiotic therapy. At admission, blood

culture-negative remained negative and TEE showed no thickening, vegetation, or periannular complications (A and B), without restriction of leaflets or THV stenosis (C and D)

and only a stable trivial anterior paravalvular regurgitation. The suspicion was rejected according to the modified Duke criteria. Multislice CT confirmed no THV abnormality

(E and F). However, the PET/CT showed an intense THV 18F-FDG-uptake (G). Thus the diagnosis was possible-IE according to the multi-imaging approach (European Society

of Cardiology 2015 modified criteria), and prolonged empirical antibiotic therapy was performed. In this case, it was impossible to conclude at a false positive of the PET/CT or

real IE with sepsis attenuated and negative blood cultures due to the initial ambulatory antibiotic therapy. Abbreviations as in Figures 1 to 3.

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ADDRESS FOR CORRESPONDENCE: Dr. Erwan Salaun, La Timone Hospital, Cardiology Department, BoulevardJean Moulin, 13005-Marseille, France. E-mail: salaun.er@gmail.com.

RE F E RENCE

1. Habib G, Lancellotti P, Antunes MJ, et al. 2015ESC Guidelines for the management of infectiveendocarditis: the Task Force for the Managementof Infective Endocarditis of the European Societyof Cardiology (ESC). Endorsed by: EuropeanAssociation for Cardio-Thoracic Surgery (EACTS),

the European Association of Nuclear Medicine(EANM). Eur Heart J 2015;36:3075–128.

KEY WORDS infective endocarditis,multi-imaging, PET/CT, TAVI, TAVR

APPENDIX For supplemental methods,results, tables, and figures, please see theonline version of this paper.