经胸与经食管超声心动图对感染性心内膜炎的诊断价值比较

  目的  比较经胸超声心动图(transthoracic echocardiography, TTE)和经食管超声心动图(transesophageal echocardiography, TEE)诊断感染性心内膜炎(infective endocarditis, IE)的准确性。  方法  回顾性分析2003年1月至2011年12月北京协和医院诊断的95例IE患者的临床及超声心动图特点, 比较TTE和TEE对赘生物和IE相关并发症的检出率, 并以TEE作为诊断IE的标准来评价TTE诊断的准确性。  结果  TEE对赘生物的阳性检出率显著高于TTE(81.1%比52.6%, P < 0.001);若以TEE阳性作为诊断IE的标准, 则TTE检出赘生物的敏感性为64.9%, 特异性为94.4%;TEE对IE瓣周并发症诊断的敏感性也显著高于TTE(P < 0.05)。  结论  TTE对赘生物检出的阳性率较低; TEE不仅在检出赘生物方面较TTE更敏感, 对IE瓣周并发症诊断的敏感性也更高。     

Endocarditis: current diagnosis and therapy]

In patients suffering from infective endocarditis (IE), initial symptoms and clinical findings are unspecific. Physicians primarily involved should always consider IE a potential diagnosis. Any delay in diagnosis and thus in an adequate antimicrobial therapy has a significant negative prognostic influence. Any subject suspected to have IE should immediately have a transthoracic echocardiography (TTE) by an experienced examiner. If the TTE results are inconclusive, transesophageal echocardiography (TEE) has to be performed without delay. Other steps in diagnosis, medical and surgical therapy follow established and evidenced-based guidelines. Antimicrobial regimens are standardized for IE, for which demonstration of causative microorganisms from blood cultures or other microbiological sources is unavoidable. If there are problems in diagnosis, if difficult-to-treat microoganisms are isolated or difficult-to-treat situations complicate active IE, a reference center should be involved.     

Transthoracic Echocardiography Is Still Useful in the Initial Evaluation of Patients With Suspected Infective Endocarditis: Evaluation of a Large Cohort at a Tertiary Referral Center

ObjectivesTo examine the sensitivity of contemporary transthoracic echocardiography (TTE) for the detection of vegetation, abscess cavity, or prosthetic valve dehiscence (Vg) in patients with suspected infective endocarditis (IE) and to identify whether a relatively normal initial TTE finding can be effectively used as a rule out test, obviating the need for transesophageal echocardiography (TEE).Patients and MethodsWe evaluated clinical, microbiological, and echocardiographic data for all patients with suspected IE referred for both TTE and TEE between January 1, 2005, and December 31, 2010. Patients were stratified into 3 groups by baseline TTE findings: negative TTE (native valves with less than or equal to mild regurgitation and no Vg), equivocal TTE (no Vg but prosthetic valve or greater than mild native valvular regurgitation), and positive TTE (Vg detected).ResultsWe studied 622 consecutive patients (68% male; mean ± SD age, 62±17 years), including 256 with Staphylococcus aureus bacteremia (SAB). The presence of Vg was confirmed by TEE in 141 patients (23%). The TTE had low sensitivity for the detection of Vg (58%). A total of 271 patients (44%) had an initial negative TTE. Of these, TEE demonstrated Vg in only 8 patients (negative predictive value [NPV] of negative TTE, 97%). The negative TTE group included 132 patients with SAB, only 6 of whom had Vg (NPV, 95%). Of 265 patients with equivocal TTE, Vg was demonstrated in 51 (19%).ConclusionIn a hospital population with clinically suspected IE, TTE had low sensitivity for the detection of Vg; however, a negative initial TTE was a common finding, with a high NPV, even in the setting of SAB. A TEE may be avoided in many patients with suspected IE.     

Appropriate use of echocardiography in managing Staphylococcus aureus bacteremia

Staphylococcus aureus bacteremia (SAB) is increasing, both in the community and in healthcare settings. Accurate and timely diagnosis of underlying infective endocarditis (IE) is critical for optimal management of SAB cases as it has significant management and prognostic implications. Reported prevalence of IE in patients with SAB varies depending on the study population, and ranges from 10 to 30%. As clinical presentation of IE can be nonspecific, echocardiography is usually recommended in SAB cases to 'rule out' IE. Due to its poor sensitivity (<50%), especially for diagnosing prosthetic valve IE, transthoracic echocardiography is considered inadequate in this setting and clinicians have to rely on transesophageal echocardiography (TEE) to confirm or exclude endocarditis in SAB cases. Although some experts recommend TEE in all patients presenting with SAB, it is believed that the use of TEE could be guided by individual patient risk factors, mode of acquisition of SAB and clinical presentation. In this article, published data regarding the use of TEE in the SAB population are reviewed and a simplified algorithm to guide use of TEE in SAB cases is proposed.     

Appropriate use of echocardiography in managing Staphylococcus aureus bacteremia

Staphylococcus aureus bacteremia (SAB) is increasing, both in the community and in healthcare settings. Accurate and timely diagnosis of underlying infective endocarditis (IE) is critical for optimal management of SAB cases as it has significant management and prognostic implications. Reported prevalence of IE in patients with SAB varies depending on the study population, and ranges from 10 to 30%. As clinical presentation of IE can be nonspecific, echocardiography is usually recommended in SAB cases to ‘rule out’ IE. Due to its poor sensitivity (<50%), especially for diagnosing prosthetic valve IE, transthoracic echocardiography is considered inadequate in this setting and clinicians have to rely on transesophageal echocardiography (TEE) to confirm or exclude endocarditis in SAB cases. Although some experts recommend TEE in all patients presenting with SAB, it is believed that the use of TEE could be guided by individual patient risk factors, mode of acquisition of SAB and clinical presentation. In this article, published data regarding the use of TEE in the SAB population are reviewed and a simplified algorithm to guide use of TEE in SAB cases is proposed.     

Sensitivity of transthoracic versus transesophageal echocardiography for the detection of native valve vegetations in the modern era.

BACKGROUND: Thirteen years ago, transthoracic echocardiography (TTE) was found to be less sensitive than transesophageal echocardiography (TEE) for native valve vegetations. Since then, harmonic imaging and other advances have improved TTE. How this affects the sensitivity of TTE is unknown. METHODS: Fifty patients with echocardiography-diagnosed endocarditis had TTE and TEE examinations on high-end machines. These were matched for date of study with 50 patients who had TTE and TEE examinations that were negative for vegetations. RESULTS: A total of 51 vegetations were seen on TEE. The sensitivity of TTE for vegetations was only 55% (aortic 50% [12/24]; mitral 62% [16/26]; tricuspid 0% [0/1]). Anatomic valvular abnormalities did not alter the sensitivity of TTE (P =.42 for mitral; P =.97 for aortic valves). However, larger vegetations were more likely to be found by TTE. CONCLUSION: Despite advances in imaging during 12 years, TTE is still insensitive compared with TEE for the detection of native valve vegetations, and fails to demonstrate nearly half of them.     

Intraoperative diagnosis of aortic pseudoaneurysm with transesophageal echocardiography

A pseudoaneurysm of the ascending aorta is a rare complication of aortic valve endocarditis that requires prompt diagnosis. Several imaging strategies can be used; however, transesophageal echocardiography (TEE) has been utilized more frequently due to its superior resolution in detection of aortic valve complications. This case presents a patient with prosthetic valve dysfunction in which intraoperative TEE was used to diagnose a previously undetected aortic pseudoaneurysm, thus leading to a change in surgical management.     

Cardiac computed tomography angiography results in diagnostic and therapeutic change in prosthetic heart valve endocarditis

Echocardiography may miss prosthetic heart valve (PHV) endocarditis which advocates for novel imaging techniques to improve diagnostic accuracy and patient outcome. The purpose of this study was to determine the complementary diagnostic value of cardiac computed tomography angiography (CTA) to the clinical routine workup including transthoracic and transesophageal echocardiography (TTE/TEE) in patients with suspected PHV endocarditis and its impact on patient treatment. A diagnostic prospective cross-sectional study was chosen as design. Besides clinical routine workup (including TTE/TEE), CTA was performed to assess its diagnostic accuracy and complementary diagnostic/therapeutic value. For the diagnostic accuracy, the reference standard was surgical findings or clinical follow-up. To determine the complementary diagnostic/therapeutic value an expert-panel was used as reference standard. Twenty-eight patients were included. CTA resulted in a major diagnostic change in six patients (21 %) mainly driven by novel detection of mycotic aneurysms by CTA. Furthermore, treatment changes occurred in seven patients (25 %) compared to clinical routine workup. Diagnostic accuracy of routine clinical workup plus CTA was superior to clinical routine workup alone for the detection of PHV endocarditis in general, vegetations and peri-annular extension. This study demonstrates that CTA and clinical workup including TTE and TEE are complementary in patients with PHV endocarditis. Therefore, CTA imaging has to be considered after clinical routine workup in patients with a high suspicion on PHV endocarditis.     

超声诊断二叶主动脉瓣合并感染性心内膜炎

目的 观察经胸超声心动图（TTE）和三维经食管超声心动图（3D-TEE）诊断二叶主动脉瓣（BAV）合并感染性心内膜炎（IE）的价值。方法 回顾性分析53例BAV合并IE患者的超声图像，超声表现包括赘生物、瓣膜穿孔、脓肿和瘘道。以外科手术所见作为金标准，评估TTE和3D-TEE的超声特征及其诊断价值。结果 3D-TEE检出赘生物、瓣膜穿孔、脓肿和瘘道的敏感度（100% vs.90.20%，96.87% vs.90.62%，92.86% vs.67.86%，94.12% vs.70.59%）和阳性预测值均高于TTE（100% vs.95.83%，100% vs.93.55%，96.30% vs.86.36%，100% vs.85.71%，P均<0.05）。结论 超声心动图对于BAV合并IE的总体检出率高。3D-TEE的可视性和空间分辨率比TTE更好，诊断BAV合并IE敏感度和阳性预测值更高。     

Utility of cardiac computed tomography scanning in the diagnosis and pre-operative evaluation of patients with infective endocarditis

Transesophageal echocardiography (TEE) is the gold standard imaging study used in the diagnosis of infective endocarditis (IE). Computed tomography angiography (CTA) has undergone rapid advancement as a cardiac imaging technique and has previously shown promise in small non-randomized studies for evaluation of IE. We hypothesized that cardiac CTA would perform similarly to TEE in the detection of endocarditic lesions and that there would be no difference in clinical outcomes whether the coronary arteries were evaluated by CTA or invasive coronary angiography (ICA). 255 adults who underwent surgery for IE at the Mayo Clinic Rochester between January 1, 2006 and June 1, 2014 were identified retrospectively. 251 patients underwent TEE and 34 patients underwent cardiac CTA. TEE had statistically higher detection of vegetations (95.6 vs. 70.0%, p?<?0.0001) and leaflet perforations (81.3 vs. 42.9%, p?=?0.02) as compared to cardiac CTA. For detection of abscess/pseudoaneurysm TEE had a similar sensitivity to cardiac CTA (90.5 vs. 78.4%, p?=?0.21). There was no significant difference in peri-operative outcomes whether coronary arteries were evaluated by CTA or ICA. The greatest advantage of cardiac CT in the setting of IE is its ability to couple the detection of complex cardiac anatomic abnormalities with coronary artery delineation, serving two important components of the diagnostic evaluation, particularly among patients who will require surgical intervention due to IE complications. Cardiac CTA may be considered as an alternate coronary artery imaging modality in IE patients with low to intermediate risk of disease but meet guideline recommendations for coronary artery imaging.     

先天性二叶主动脉瓣畸形的超声诊断价值

目的分析先天性二叶主动脉瓣畸形(BAVD)的多普勒超声表现,以提高对该病的认识.方法采用Acuson 128xp10及Sequoia256彩超仪,通过经胸超声(TTE)及经食道超声(TEE)检测44例(BAVD)患者的主动脉瓣表现、并发症.结果BAVD在大动脉短轴切面上为两个瓣膜及两个瓣膜联合点,舒张期呈单一关闭线,75%患者有不同程度瓣膜受损.主动脉瓣狭窄(AS)占34%,主动脉瓣关闭不全(AR)占68%,升主动脉扩张占30%;合并主动脉瓣赘生物5例,伴二尖瓣病变5例,房间隔缺及膜周部室缺各1例.结论BAVD可出现不同程度的AS及AR和由此所致的各种血流动力学异常,可伴多种先天及后天性心血管异常.多谱勒超声是诊断BAVD及其并发症的最佳方法.     

多平面经食管超声心动图临床应用

目的：研究多平面经食管超声波心动图（multiplane TEE）的临床应用价值。方法：于经胸彩色二维多普勒超声心动图（TTE）检查效果不满意或诊断不明确的180例患者行多平面TEE检查。结果：多平面TEE定性诊断准确度明显高于TTE,90例（50%）患者多平面TEE完全及部分改变了TTE的诊断。结论 多平现TEE检查创伤小,操作简便,是一项安全可靠的心血管超声诊断技术,有较高的临床应用价值。     

经食管与经胸超声心动图对主动脉瓣畸形的诊断价值比较

目的：比较经食管与经胸超声心动图（TEE与TTE）对主动瓣畸形的诊断价值。方法：应用TTE和TEE对35例主动脉瓣畸形进行诊断,并与手术结果对照。结果：两种方法均有较高的诊断价值,两者比较TEE诊断准确率明显高于TTE,有显著性差异。结论：TTE简便易行,为TEE筛选病例。TEE是目前诊断本病最准确,可靠的方法,具有重要临床价值。     

Transesophageal echocardiography in the diagnosis of thrombosis associated with permanent transvenous pacemaker electrodes

OBJECTIVES: We sought to assess the value of transesophageal echocardiography (TEE) in the diagnosis of PM-lead-associated central venous thrombi. BACKGROUND: Venous thrombosis is not infrequent after pacemaker (PM) or implantable cardioverter-defibrillator (ICD) implantation. Previous incidence studies of thrombosis have been based on venography or Doppler ultrasound, but the role of TEE has not been systematically evaluated in this setting. METHODS: Study group comprised 66 consecutive patients (mean age 64 years, 67 % male) referred for implantation of their first PM or ICD and with a successful TEE, transthoracic echocardiography (TTE) and venography at 6 months after implantation. The total number of implanted leads was 110. During the 6 months of clinical follow-up, nuclear ventilation-perfusion scan or spiral computed tomography was performed when symptoms aroused a clinical suspicion of PE. RESULTS: TEE revealed a right atrium (RA) or lower superior vena cava (SVC) thrombus in 6 (9%) patients. These thrombi were not visualized by TTE or venography. Additionally, 12 (20%) patients were found to have venographic subclavian or innominate vein thrombi, but none of those could be diagnosed with TEE. Symptomatic pulmonary embolism (PE) was diagnosed in two and an asymptomatic PE in one individual and two of these occurred among the six patients with a thrombus in TEE. No clinical predictors for thrombosis were found. CONCLUSIONS: TEE is an excellent method to visualize electrodes within the RA and proximal SVC. Electrode-associated RA thrombi appear to be relatively common after PM implantation, and they may remain undetectable by venography or TTE. Although these thrombi are mostly asymptomatic, they can give rise to pulmonary embolism and should also be kept in mind in the differential diagnosis of endocarditis. TEE is the method of choice for the diagnosis of these lesions.     

经胸及经食管超声心动图对二尖瓣腱索部分断裂的诊断价值比较

目的比较经胸超声心动图（ＴＴＥ）及经食管超声心动图（ＴＥＥ）对二尖瓣腱索部分断裂的诊断价值,探讨ＴＥＥ对该病的探测方法及其声像学特征。方法应用ＴＴＥ和双平面及多平面ＴＥＥ检查３８个病例,检查结果与手术资料相对照。结果ＴＥＥ和ＴＴＥ对二尖瓣腱索部分断裂的切面超声征象包括收缩期瓣缘对合不良、局部链枷运动、局部粗大扑动、腱索断端飞鞭运动伴粗大扑动及赘生物的检出率分别为１００％和９４．３％、１００％和６５．７％、８５．７％和５４．３％、７７．１％和４８．６％及１００％和３３．３％;ＴＥＥ和ＴＴＥ二尖瓣腱索断裂的彩色多普勒表现为偏心附壁返流束或偏心伴向心返流束,其检出率均为１００％;根据ＰＩＳＡ法由ＴＥＥ及ＴＴＥ估测的返流量分别为（２０２５±４０２）及（６０７±２６８）ｍｌ／ｍｉｎ。ＴＥＥ和ＴＴＥ对本病的确诊率分别为１００％和６０．５％,疑诊率０和１５．８％,漏诊率０和１５．８％,误诊率０和７．９％。结论ＴＥＥ对二尖瓣腱索部分断裂异常超声征象的检出率显著高于ＴＴＥ,对其诊断的准确性也显著高于ＴＴＥ。     

经胸超声心动图对感染性心内膜炎严重并发症的诊断价值和术后疗效评价

目的探讨经胸超声心动图在感染性心内膜炎严重并发症诊断及术后疗效评价中的应用价值。方法分析512例感染性心内膜炎中32例严重并发症,包括脓肿、膨出瘤、假性动脉瘤、假性室壁瘤或房壁瘤以及窦道或心腔间交通和赘生物脱落栓塞的超声心动图表现及临床特征,并与手术结果对照;赘生物脱落栓塞3例同时与多排CT对照。结果 32例中31例与手术结果完全相符,经胸超声诊断符合率为96.9%。1例误诊(1/32),手术证实为主动脉窦瘤破裂入左心室。超声诊断栓塞3例,均经多排CT检查证实。结论经胸超声心动图能及时、快速、准确的诊断感染性心内膜炎的严重并发症,指导临床治疗,改善预后,并在术后疗效随访中有重要价值。     

三维超声评估感染性心内膜炎栓塞事件及住院死亡的危险特征

目的 采用三维经食管超声心动图评估感染性心内膜炎栓塞及住院死亡的超声特征。方法 回顾性收集124例自体瓣膜感染性心内膜炎患者,分析其经胸二维超声、多平面和三维经食管超声特征。将手术前或后1个月内栓塞和死亡作为主要终点事件。将大赘生物、脓肿或瘘、腱索断裂、中重度瓣膜反流和瓣膜穿孔或严重瓣膜破坏各计1分,进行简单积分,对心脏受损累计简单积分、赘生物大小、瓣膜受损严重并失去正常形态结构采用Hosmer和ROC曲线下面积评估栓塞和不良事件。结果 124例患者中,27例（27/124,21.77%）患者发生栓塞。与二维经胸超声心动图比较,多平面和三维经食管超声心动图可识别赘生物的确切位置及其长度,而二维经胸超声心动图漏诊左心房和乳头肌赘生物。栓塞及不良事件患者血红蛋白显著低于非栓塞及不良事件患者（P<0.05）。栓塞及不良事件患者多部位赘生物形成、赘生物活动度和瓣膜严重受损并失去正常形态构成比均高于非栓塞及不良事件患者（P均<0.05）。感染性心内膜炎心脏受损累计简单积分、赘生物大小、瓣膜严重受损并失去正常形态结构曲线下面积分别为0.65（P=0.06）、0.60（P=0.19）、0.70（P=0.03）。结论 多平面及三维经食管超声对感染性心内膜炎,尤其位于不常见位置的赘生物诊断起重要作用。瓣膜严重受损并失去正常形态者与栓塞及不良事件有关。     

Clinical features remain important for the diagnosis of infective endocarditis in the modern era

BACKGROUND: Infective endocarditis (IE) can be difficult to diagnose, due to multiple (often non-specific) presenting features. AIM: To assess the predictive accuracy of classical clinical features and blood investigations readily available at the time of presentation. DESIGN: Cross-sectional analysis. METHODS: We studied 29 IE cases and 79 controls (clinically suspicious contemporaneous cases where IE was subsequently excluded) from a hospital-based group of patients referred to a cardiac department with possible infective endocarditis. Patients were identified from the echocardiography database. Cases were defined by final diagnosis. Symptoms, signs, risk factors for IE and blood investigations were recorded from case notes and examined by univariate and multivariate analyses. RESULTS: The sensitivity, specificity, and positive and negative predictive values of transthoracic echocardiography (TTE) for detection of IE in clinically suspected cases were 71%, 98%, 57% and 99%, respectively. Univariate analyses revealed a significant association between IE and several clinical features. Under multivariate analysis, previous heart valve surgery (OR 13.3, 90%CI 3.2-55.6), positive blood cultures (OR 17.2, 90%CI 4.9-58.8), signs of embolism (OR 11.4, 90%CI 3.0-43.5), a new, altered or changing murmur (OR 10.3, 90%CI 2.8-38.5) and splenomegaly (OR 18.2, 90%CI 3.6-90.9) were independent predictors for IE. DISCUSSION: Clinical features at presentation continue to be important for the diagnosis of IE. Features such as positive blood cultures, signs of embolism and a changing heart murmur should be used to guide investigation and treatment of IE prior to echocardiography, or when TTE is negative.     

Potential applications for transesophageal echocardiography in hypertrophic cardiomyopathies.

The purpose of the present study was to evaluate the potential advantages of transesophageal echocardiography (TEE) in comparison with transthoracic echocardiography (TTE) in selected patients with hypertrophic cardiomyopathy. Ten patients with previously established or suspected diagnosis of hypertrophic cardiomyopathy were examined by TEE to solve specific clinical questions. TEE was well tolerated by all patients; no arrhythmias were seen during the procedure. The comparison of TTE and TEE showed the following: Advantages of TTE--better assessment of the left ventricle, myocardial thickness measurements available in all regions and sufficient for the diagnosis of hypertrophic cardiomyopathy in nine out of 10 patients; advantages of TEE--precise assessment of mitral valve morphology and regurgitant jets, detailed evaluation of systolic anterior motion, and subaortic membrane (not seen by TTE) recognized in one patient. Clinically, in three patients TEE influenced the management (mitral leaflet perforation, subaortic membrane, and residual mitral regurgitation after valvuloplasty). Thus TEE enables more precise diagnosis in some patients with hypertrophic cardiomyopathy and has the potential to influence their surgical management. However, for medical treatment of hypertrophic cardiomyopathy, TTE is sufficient.     

心外科房间隔缺损封堵术中经食管超声心动图的应用价值

目的评价经食管超声心动图（TEE）监测房间隔缺损封堵术的临床价值。方法手术前应用经胸超声心动图（TTE）及TEE筛选符合条件的100例单纯房间隔缺损（ASD）患者行封堵术;手术中TEE监测整个封堵过程和引导封堵伞的放置;手术后评价封堵效果、残余分流或并发症等。结果 100例患者均应用TTE和TEE确诊,导引和监测成功闭合房间隔缺损。技术成功96例,成功率96%;4例失败,失败率4%。手术后复查无1例残余分流,3例胸腔积液。经胸超声心动图与TEE诊断结果完全一致率40%,TEE诊断对手术前TTE诊断做出补充或修正诊断的有60例（60%）。结论 TEE对选择适合行封堵术者、选择封堵器大小、指导封堵器的释放、以及疗效评价均具有重要的作用。