Role of 18F-FDG PET/CT in the diagnosis of infective endocarditis in patients with an implanted cardiac device: a prospective study

Abstract

In patients with a cardiac device, PET/CT increases the diagnostic accuracy of the modified Duke criteria for IE, particularly in the subset of patients with possible IE in whom it may help the clinician manage a challenging situation.

18F-FDG PET/CT now endorsed by guidelines across all types of CIED infection: Evidence limited but growing

“…However, false negatives and reduced sensitivity have been described in studies reporting pre-treatment with antibiotics. 18,28,33 Although perhaps not always deliverable in a real-world setting, patients would be ideally be scanned before the administration of antibiotics to ensure greater confidence in excluding infection.…”

Positron Emission Tomography/Computed Tomography Imaging in Device Infective Endocarditis

“…For improving the accuracy of the Duke criteria, other imaging modalities such as multidetector computed tomography (CT), 18 F-fluorodeoxyglucose (FDG) positron emission tomography (PET), and single-photon emission computed tomography (SPECT) have recently gained importance. [6][7][8][9][10][11][12][13][14][15][16][17][18][19] With the use of retrospective ECG-gated acquisitions and intravenous contrast to enhance vascular structures, currentgeneration CT scanners provide enough spatial detail to visualize the valvular structures at several different phases of the cardiac cycle without motion artifact. The so-called cardiac CT angiography (CTA) is possibly superior to TEE for the evaluation of perivalvular complications such as abscesses and pseudoaneurysms or fistulae.…”

“…The integration of the anatomic detail provided by unenhanced CT with metabolic imaging (SPECT/CT and PET/CT) has improved the accuracy and utility of this approach. Several reports have highlighted the potential added value of SPECT/ CT imaging of radiolabeled leukocytes and 18 F-FDG PET/CT in the diagnosis of DIE in patients with a negative or inconclusive routine workup with transthoracic echocardiography and TEE [9][10][11][12][13][14][15][16][17][18][19] (Table). Radiolabeled leukocyte SPECT/CT imaging seems to be more specific for the detection of infective endocarditis and infectious foci than 18 F-FDG PET/CT.…”

“…Similar data have been reported in CDRIE with the possibility of assessing the extension of the infectious process and differentiating between DIE and other postimplantation phenomena (eg, pocket hematoma, inflammation). [9][10][11][12][13][14] Interestingly, several reports showed that FDG-PET/CT could detect clinically unsuspected sites of extracardiac infection in up to 10% to 28% of cases. 18,19 In this issue of Circulation, Pizzi et al 17 evaluated the incremental value of 18 F-FDG-PET imaging in association with CT(A) over the modified Duke score at admission for the diagnosis of infective endocarditis in 75 patients with PV or cardiac devices (mostly cardiac implantable electronic devices).…”

“…[9][10][11][12][13][14][15][16] The benefits of PET/CT(A) are mostly related to the early identification of endocardial involvements, better evaluation of perivalvular lesions, and documentation of extracardiac complications (silent embolic events or metastatic infectious events) or associated features (ie, neoplastic lesions; Figure). Abnormal FDG (or radiolabeled leukocyte SPECT) uptake around PV and definite perivalvular lesions on cardiac CT are considered major Duke criteria in the 2015 European Society of Cardiology guidelines, whereas an embolic event detected by imaging only represents a minor criterion.…”