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More Evidence Supporting Fluorodeoxyglucose Positron Emission Tomography for Diagnosing Prosthetic Valve Infective Endocarditis

Prosthetic valve endocarditis (PVE) may affect up to 5% of individuals after valve replacement, and appears more common than previously reported.1 Its diagnosis is challenging because the Modified Duke Criteria2 rely on transesophageal echocardiography and blood cultures.3 However, the diagnostic accuracy of echocardiography in individuals with prosthetic valves is lower than native valves, and blood cultures results may be delayed.4 Because delays in diagnosis are associated with exceedingly high complication rates and mortality, there is an unmet clinical need for new faster more accurate diagnostic strategies. Recent studies have proposed that 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) may have adequate diagnostic accuracy to be routinely used in the investigation of infective endocarditis, with a particularly good performance for PVE.5 In this scenario, an incremental diagnostic accuracy when compared to usual care has been demonstrated.6,7 Consequently, the European Society of Cardiology Guidelines now include 18F-FDG PET and cardiac CT findings as major criteria for diagnosing PVE when the level of suspicion is high, but the diagnosis is not confirmed.8 Nevertheless, at the present time neither 18F-FDG PET nor cardiac CT are recommended by the US guidelines for diagnosing infective endocarditis.9 In the current issue of Circulation, Swart et al10 provide further evidence to support the value of 18F-FDG PET in diagnosing PVE. The authors retrospectively evaluated 160 patients from 6 centers in the Netherlands with suspected PVE who underwent 18F-FDG PET. These included 82 patients with mechanical valves, 62 patients with biological valves, and 9 patients with TAVR valves. The reference standard included a comprehensive approach, whereby the diagnosis was either confirmed by surgery/histopathology or rejected by an uneventful 1-year follow-up without antibiotic therapy. In cases where there was uncertainty, a multidisciplinary “endocarditis team” was used to establish consensus. When a visual assessment of 18F-FDG PET was compared with this reference standard, a sensitivity of 74% and specificity of 91% were observed, results which are in keeping with previously published studies.6,7 In contrast, echocardiography alone had a sensitivity of 65% and specificity of 85%. However, when 18F-FDG PET was combined with other clinical data (as is often done in clinical practice), the combined sensitivity and specificity reached 96% and 100%, respectively. Swart and colleagues10 extend prior knowledge in this field by addressing 2 important questions: (1) What factors are associated with lower accuracy of 18F-FDG PET? (2) Can the accuracy of 18F-FDG PET be improved by a quantitative assessment of the target-to-background standardized uptake value ratio? To identify potential confounders related to the diagnostic accuracy of 18F-FDG PET, the authors used logistic regression © 2018 American Heart Association, Inc.