Similar to TTE, there are limited studies with small patient cohorts assessing the diagnostic accuracy of TEE for identifying the complications of IE, other than vegetation and abscess. Over time, equipment has dramatically improved with the latest TEE matrix array transducers composed of up to almost piezoelectric elements. This leap of technology has been accompanied by improved digital processing power and miniaturization, along with other software and hardware improvements. Live 3D and 3D zoom modes are single-beat acquisitions and represent cardiac structure and function in real time.
Single-beat full volume is available; however, it is limited by reduced temporal and spatial resolution. The role of 3D echocardiographic imaging of vegetations is not well studied. A few case reports or small series confirm, as would be expected, that 3D TEE provides better morphological characterization and localization of lesions compared to 2D TEE. Three-dimensional TEE was shown to improve detection of vegetations in some case reports [ 88 — 91 ]; however, small vegetations may theoretically be more reliably detected with 2D due to higher temporal and spatial resolution.
A major benefit of 3D is the ability to visualize the entire valve and annulus in a single beat, enabling identification of eccentrically located vegetations that may otherwise be missed on a standard 2D TEE examination. Also, 3D imaging provides more accurate assessment of vegetation size. In a direct comparison by Berdejo et al. However, 3D TEE imaging has been shown in case reports to provide useful additional information regarding the periannular extent of abscess and the relation to surrounding anatomical structures, including the coronary arteries [ 90 , 93 ].
To confirm the finding, the defect should be visualized in systole and diastole and associated with a thickened rim surrounding the perforation [ 96 ]. Finally, 3D may assist with surgical planning when repair is contemplated [ 94 , 96 ]. Three-dimensional TEE has the potential to demonstrate the extent and location of a valve aneurysm with greater accuracy than 2D imaging [ 97 ]. Similarly with perivalvular dehiscence, 3D is able to define the anatomic spatial relationship to surrounding structures and accurately define the location, size, and extent of the pathology [ 93 ].
One study showed the added benefit of 3D contrast TTE for accurately delineating the size and extent of a left ventricular pseudoaneurysm, when compared to 2D contrast TTE [ 98 ]. The role of 3D echo for right-sided IE is restricted to case reports and small case series [ 99 , ]. Sungur et al. Three-dimensional imaging provided en-face visualization of all three TV leaflets in nine of 10 cases, allowing accurate identification and localization of multiple vegetations. In addition, 3D was able to better characterize vegetation morphology and size.
Three-dimensional TEE may add incremental value in localizing vegetations that are partly obscured by reverberation artifact on 2D imaging [ 99 ]. Because the right heart is located anteriorly in the chest, 3D TTE is particularly useful and has the potential to provide better imaging of the tricuspid valve.
Echocardiography, especially TTE, has a number of potential limitations due to patient and nonpatient factors. TTE image quality is influenced by body habitus, chest wall deformity, rib space size, and interposing lung tissue. Furthermore, the skills of the sonographer and echocardiologist also influence diagnostic accuracy as shown by interobserver variability.
Clinical history is important to the reporting echocardiographer but may result in bias with a trade-off between sensitivity and specificity [ , ]. The ultrasound equipment, machine settings, and transducer frequency all impact on diagnostic accuracy. The limits of image resolution allow detection of vegetations down to 1. Not surprisingly, it has been shown that smaller vegetation size reduces the sensitivity of TTE [ 54 , ]. Mimickers of vegetations are often responsible for false-positive findings.
Examples include degenerative valvular tissue, calcification, flail chords, thrombus, tumor, artifact from calcium or prosthetic material, and even normal anatomical variants such as a prominent Eustachian valve. Small thin linear strands are common and are frequently seen on native valves along the leaflet coaptation zone and may be confused with vegetations. The limitations outlined underscore the need to repeat imaging in due course usually within one week if the initial TTE and TEE are both negative, but there remains ongoing clinical suspicion of IE.
Embolism occurs in approximately one-quarter to one-half of patients [ , ] with endocarditis, but the risk is substantially reduced after initiation of antibiotics within the first 1—2 weeks [ , ]. Large mobile vegetations are associated with more complications. Previous embolism, change in size of vegetations, S. Echocardiography is very useful at identifying important prognostic markers related to extent of infection, cardiac function, and hemodynamics. Predictors of outcome include periannular extension, severe valvular dysfunction, left and right ventricular systolic function, left atrial size, left ventricular size, left ventricular filling pressures, and pulmonary artery pressure [ 1 , , , ].
More specifically, in left-sided native valve S. Early surgery within the first week of antimicrobial therapy can improve survival in complicated left-sided IE; however, it may increase the risk of relapse and prosthetic valve dysfunction [ ]. Echocardiography is fundamental in identifying important complications and prognostic markers that influence the timing of surgery.
Heart failure and embolism are the leading causes of mortality. Perioperative pre-pump 2D and 3D TEE provides the surgeon with a comprehensive real-time assessment of the extent of intracardiac pathology and cardiac hemodynamic status immediately prior to the procedure. A decision can be made on the feasibility of repair versus valve replacement and allows planning of the surgical strategy. The postpump TEE assesses cardiac function, hemodynamics, and the adequacy of surgical procedure. Intraoperative TEE for IE has been shown to positively impact on at least one of these factors in approximately one-third of operations [ ].
Image optimization is particularly important in IE to ensure early diagnosis and accurate identification of complications. A TEE probe is in close proximity to the heart, with minimal intervening tissues and therefore less attenuation of the ultrasound waves. This allows the use of a higher frequency 5—7. To obtain superior spatial resolution, select the highest frequency transducer that will maintain adequate depth penetration.
Position the focal zone adjacent to the region of interest and adjust depth and sector width to optimize spatial and temporal resolution [ 47 , ]. Gain, time gain compensation TGC , and dynamic compression of the gray scale are adjusted to optimize image contrast, while zoom function in real time improves spatial and temporal resolution [ ]. Three-dimensional image resolution is dependent on the quality of the 2D picture; therefore, optimizing the image prior to changing to 3D mode is essential.
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Select the imaging plane or acoustic window with the highest resolution. Imaging in the axial plane provides superior resolution 0. When performing 3D TTE, select the window that transects the structure of interest through the axial and lateral plane such as the parasternal long axis for the mitral valve. To allow for optimal postprocessing, it is recommended the gain, compensation, and compression be in the midrange, with the TGC adjusted to display a uniform, slightly brighter image [ ].
As spatial resolution increases, temporal resolution is reduced and vice versa. This is due to the limited number of scan lines that can be performed in a fixed period of time. To improve image resolution, narrow the sector width and optimize frequency, compression, and focus [ , ]. This can be addressed with breath holding and ensuring image acquisition during regular R-R intervals on the ECG.
Cropping of the 3D dataset can be performed en cart prior to image storage or alternatively, offline on a workstation using proprietary software. The 3D data can then be displayed as volume rendered format and surface rendered format or 2D tomographic slices [ ]. Finally, the 3D rendered image is rotated and orientated according to convention. The display formats remain the same regardless of whether the valve is viewed from above or below [ ].
Use zoom mode to focus on each valve individually to ensure subtle pathology is not overlooked. It is important to pan through the cardiac valves and adjacent supporting structures using multiple angles and off-axis imaging. This can be achieved with TEE probe manipulation, such as anteflexion, retroflexion, lateral flexion, probe turning, and probe advancement or withdrawal. Careful manipulation of the probe is required to avoid trauma or perforation of the upper gastrointestinal tract. Similarly, the TTE transducer can be angulated, rotated, or repositioned on the chest wall to maximize diagnostic utility.
With the introduction of multiplane TEE, the 2D image can be effortlessly rotated through degrees. Thorough inspection of the valves, with 2D and color flow Doppler, should be undertaken at frequent intervals, as the angle is increased. Interrogation of valvular function with color Doppler along with hemodynamic assessment is essential. Attention should be paid to abnormal color flow arising from valves, fistulae, or other shunts.
Images along the direction and path of any pathological color flow are used to identify abnormal communications and exclude jet lesions. Assess cardiac chambers for mural vegetations and the vasculature for endarteritis. Finally, it is imperative to complete a comprehensive echocardiographic study to assess cardiac function, hemodynamics, filling pressures, and pulmonary artery pressure.
Three-dimensional functionalities such as X-plane, real-time, and multibeat 3D should be routinely incorporated, especially for TEE examination of the mitral and aortic valves. Transthoracic 3D of the tricuspid valve is useful for assessing valve anatomy and pathology, particularly in patients with regurgitation associated with pacing leads [ ].
For valvular complications of endocarditis, 3D zoom is preferred, providing good spatial and temporal resolution with a single-beat acquisition [ ]. However, if assessing extensive perivalvular pathology or ventricular size and function, then change to a wide-angle full-volume 3D multibeat acquisition. Leading echocardiography laboratories must ensure that high standards are accomplished both for clinical practice and for scientific research. Recommendations for core laboratories, including quality control guidelines, have been published by the American Society of Echocardiography [ , ] and European Association of Echocardiography Cardiovascular Imaging [ ].
Periodic auditing of stored images and reports should be undertaken and reviewed by an experienced physician. Echocardiographic findings of endocarditis should undergo pathological correlation with surgery or a complimentary imaging modality, such as cardiac CT. For a center to develop excellence in endocarditis management, a dedicated imaging and clinical database should be established for auditing, quality control, and research purposes.
Recent guidelines recommend the establishment of a specialized multidisciplinary team at centers with expertise in managing IE [ ]. The endocarditis team should be engaged early in the management of suspected IE and urgent echocardiography performed. The lead echocardiologist should have expertise in the field of cardiac infection and provide ongoing education to medical colleagues and sonographers alike to ensure the highest imaging standards are met. When IE is suspected on echo, expert interpretation of the findings should be communicated urgently to the treating team, especially when significant pathology is identified.
The echocardiologist is also able to advise of any requirement for a supplemental procedure, such as TEE or CT, and provide recommendations with regard to appropriate follow-up imaging [ 17 , 27 , , ]. Intracardiac echocardiography ICE has the potential to provide better image quality than TEE due to its use of higher frequency ultrasound in close proximity to the right-sided cardiac structures. Narducci et al. Although ICE is considered a safe procedure [ , ], its routine use is limited by cost. Future applications include the use of 3D ICE and electroanatomic mapping [ ]. The application of targeted microbubbles and molecular contrast imaging offers promise as an emerging field of research.
Contrast agents could be designed to tag certain cellular or molecular markers, such as inflammatory cells or ligands, enabling contrast imaging to detect the presence, location, and extent of the targeted pathology [ ]. Multislice CT shows similar diagnostic performance to TEE for detection of large native and prosthetic valve vegetations, valve aneurysm, abscess, and pseudoaneurysm and provides superior anatomical detail relating to the extent of periannular extension and relation to surrounding structures.
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Twenty-Year Experience in the Diagnosis and Treatment of Infective Endocarditis
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