P983How should we interpret the findings of possible vegetation during transesophageal echocardiography in patients with suspected infective endocarditis?


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Abstract

In the recently modified Duke criteria fordiagnosis of infective endocarditis (IE), the category of "possible vegetation"has been omitted, only considering a certain diagnosis of presence or absenceof vegetations. How doubtful findings in the context of alternative diagnosesshould be considered remains unclear.Objective: To characterize the echocardiographic and microbiological data in patients with suspected infective endocarditis (IE)and an uncertain transesophageal echocardiography (TEE)Methods and Results: During years 2009 and 2010, all patients referred for transesophageal echocardiography (TEE) to rule out IEbased on clinical and/or microbiological criteria were prospectively enrolled.TEE studies were classified by one level III echocardiography expert asnegative (no images of vegetation), positive (clear vegetation and/or IE related complications) or possible vegetation (abnormal images requiring a differential diagnostic between IE andother etiologies such as surgical debris, Lambl's excrescences, rupturedchordae, thrombi, etc.). Images were classified by location, mobility and size.After mid-term clinical, echocardiographic and microbiological follow up acertain diagnostic of IE was established or excluded based on modified Dukecriteria.A total of 431 patients were included. Ofthese, 33 patients (7%) were positive, 325 patients (74%) negative for thediagnosis of IE. Uncertain findings of "possible vegetations" were found in 73patients (17%). Blood cultures were positive in 56% of these 73 patients: S. aureus 39%, S Streptococcus 29%, S. epidermidis 12%, C. albicans 8% and Enterococcus2%. A second TEE exam was performed in 53% (39) of the patients with uncertainfindings 9.5 ± 3.3 days after the first exam; inthese 31% (12) were negatives, 33% (13) uncertain and 36% (14) positive forvegetation. In five of 13 patients with an uncertain finding on the second TEE and high clinical suspicious of IE a third TEE was performed and showed clearpositive findings of IE in the third exam. Uncertain findings were observed in41% of the cases in native valves, 38% in prosthetic valves, and 21% onintracardiac catheters. 5% of patients presented an abscess as an IEcomplication. The most common anatomical features of uncertain images were highmobility (77%), thin shape (74%) and a small (< 5mm) size (56%).Conclusions: Not a small number of patients with clinical suspected IE present with a first TEE of "possible vegetation". Clinical judgement must guide further examinations, as approximately half of these patients will eventually show a positive diagnosis of IE according to the Dukecriteria.

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