Role of Negative Trans-Thoracic Echocardiography in the Diagnosis of Infective Endocarditis.

BACKGROUND: The search for the presence of vegetations in patients with suspected infective endocarditis is a major indication for trans-esophageal echocardiographic (TEE) examinations. Advances in harmonic imaging and ongoing improvement in modern echocardiographic systems allow adequate quality of diagnostic images in most patients. OBJECTIVES: To investigate whether TEE examinations are always necessary for the assessment of patients with suspected infective endocarditis. METHODS: During 2012-2014 230 trans-thoracic echo (TTE) exams in patients with suspected infective endocarditis were performed at our center. Demographic, epidemiological, clinical and echocardiographic data were collected and analyzed, and the final clinical diagnosis and outcome were determined. RESULTS: Of 230 patients, 24 had definite infective endocarditis by clinical assessment. TEE examination was undertaken in 76 of the 230 patients based on the clinical decision of the attending physician. All TTE exams were classified as: (i) positive, i.e., vegetations present; (ii) clearly negative; or (iii) non-conclusive. Of the 92 with clearly negative TTE exams, 20 underwent TEE and all were negative. All clearly negative patients had native valves, adequate quality images, and in all 92 the final diagnosis was not infective endocarditis. Thus, the negative predictive value of a clearly negative TTE examination was 100%. CONCLUSIONS: In patients with native cardiac valves referred for evaluation for infective endocarditis, an adequate quality TTE with clearly negative examination may be sufficient for the diagnosis.

Clinical significance and prevalence of valvular strands during routine echo examinations.

AIMS: Lambl's excrescences (valvular strands) have been associated with an increased embolic risk. In previous studies, valvular strands have mostly been detected by transoesophageal echo (TEE). The current high-resolution echo systems allow better detection of valvular strands often even by transthoracic echocardiography (TTE). We attempted to determine the incidence of valvular strands during routine echo exams, TTE and/or TEE, and their relation to the cardiovascular risk factor, co-morbidities, and outcome. METHODS AND RESULTS: Over 21 000 echo exams were performed at our hospital during 2008-12 and were searched for reporting of valvular strands. One hundred and fifty such studies were identified and the presence of valvular strands was confirmed. These patients were then evaluated for clinical characteristics, co-morbidities, and outcome, and compared with 150 age- and gender-matched patients without valvular strands. Incidence of valvular strands was maximal at age 61-70 (0.94%), and they were found more commonly in men than in women, 92 vs. 58, P < 0.00001. Valvular strands occurred more often on the aortic than on the mitral valve, 125 vs. 36, respectively, P < 0.00001, were more often associated with thickened or calcified aortic or mitral valve, and occupied the ventricular side of the aortic valve and the atrial side of the mitral valve, P < 0.00001. Embolic events occurred in 40 of the 150 patients with strands (27%). Valvular strands were not associated with increased mortality. CONCLUSION: Valvular strands (Lambl's excrescences) appear not to affect life expectancy, but are often associated with embolic/cerebrovascular events, are more common in older patients, in men than in women, and are more commonly located on the aortic than on the mitral valve.