SHM Converge Scientific Abstract ePoster Gallery-When Echocardiography Isn't Enough: Pet/Ct in the Diagnosis of Endocarditis

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This case highlights the value of PET/CT when echocardiography is inconclusive in suspected prosthetic valve endocarditis (PVE).<br /><br />A 70-year-old woman with prior Streptococcus agalactiae native valve endocarditis complicated by embolic thalamic infarcts underwent porcine mitral valve replacement seven months earlier. She later presented with generalized weakness and fatigue and developed fever with multiple blood cultures growing MRSA. Transthoracic echocardiogram showed echodensities concerning for mitral valve vegetations, so she was treated with vancomycin, gentamicin, and rifampin. However, transesophageal echocardiogram (TEE), the usual most sensitive imaging test for infective endocarditis, showed no vegetations. Because clinical suspicion remained high, PET/CT was obtained. It demonstrated intense circumferential FDG uptake around the mitral prosthesis, strongly suggesting prosthetic valve infection, as well as a cavitary lung lesion. Cardiothoracic surgery recommended nonoperative management, and she continued medical therapy with outpatient follow-up.<br /><br />The discussion emphasizes that while TEE is highly sensitive and specific, it can miss PVE in up to 20% of cases, especially with prosthetic material. The revised 2023 Duke Criteria now include PET/CT as an additional major imaging criterion. PET/CT is particularly useful for identifying abnormal metabolic activity involving prosthetic valves and can also reveal extracardiac septic foci. Its limitations include reduced sensitivity in native-valve endocarditis, need to delay imaging after recent valve implantation, decreased performance after antibiotics, and limited availability.<br /><br />Overall, this case illustrates that PET/CT can meaningfully improve diagnosis and management of PVE when TEE is negative but suspicion remains high.

Asset Subtitle

Colleen McCarthy

Meta Tag

Author List Colleen McCarthy, Cynthia Zheng, Rachel Simmons

Category Clinical Vignettes

Concept Transesophageal Echocardiography

Concept Infective Endocarditis

Concept Prosthetic valve endocarditis

Concept PSMA PET/CT

Concept Modified Duke Criteria

Distinguished Non-Finalist

Presenter Organization Warren Alpert Medical School of Brown University

Presenting Author Colleen McCarthy

Track Adult

Keywords

prosthetic valve endocarditis

PET/CT

transesophageal echocardiogram

mitral valve replacement

MRSA bacteremia

FDG uptake

infective endocarditis

Duke Criteria

prosthetic valve infection

cavitary lung lesion

Transesophageal Echocardiography

Infective Endocarditis

Prosthetic valve endocarditis

PSMA PET/CT

Modified Duke Criteria