Stephen H. Little, MD and Mouaz Al-Mallah, MD discuss endocarditis and the role of Echo, CT, CMR, PET.
Well, hello. Thank you for joining us for this multi modality imaging conference on endocarditis. Uh, my name is Steven Little. Uh, joining me is my colleague, Dr Almallah. Uh, today we're gonna sort of split this topic and look at it from two ways. I'm gonna talk about the echo components on Dr Omalu. We'll talk about sort of the CTC Amar and the pet imaging of endocarditis. I'll try to give him a three or four minutes at the end to accomplish all that. All right, so we'll get started here, and I'll take you through some of the echo issues with endocarditis. I think the first thing to recognize is really the definition of what is the vegetation, which is really the hallmark of the imaging friend of Carnitas. And in this example, you see a few things. This is a native mitral valve with a na vi ous mobile mass. And this mass can be described is it's a mass. It's moving. But the key term here is that it's oscillating. So it does have elements that move in a way that air independent to simply following the cardiac cycle. So that's what oscillation means and That's eyes one of the hallmark features of most forms of endocarditis. This is another example smaller, um, mobile Mass. Which does have that sort of oscillation whip like motion, which is different than prosthetic materials different than, um, typically throwing This would do. And that's the truck custard valve in an I V drug user. So another feature sort of very general feature of endocarditis is that it does tend to accumulate on the flow surfaces. So that's, ah, rule and all rules could be broken. But as a general feature of the imaging, you'll tend to see this feature. So this is, ah, mitral valve that tends to be the flow surface on the mitral valve is the atrial side. The flow surface on the aortic valve is the ventricular site, so in general, when you do see a stock of a vegetation, it tends to be on the flow surface. The reason being is that's the surface that is denuded and and suffers the inflammation cellular breakdown. And ultimately that's where the lesions occur. So the pathogenesis of infective endocarditis should be recognized. It really does start with that tissue disruption and Otho Liel damage eso that really has to be the first step. So it is not easy to create an infection focal infection on a completely healthy valve. It is possible certain, very virulent bacteria. But in general there's something abnormal, whether it's prosthetic tissue. Ah, congenital abnormality with jet lesions in different forms of inflammation. But there is typically endothelial abnormality to begin with you, then get some fiber and depositions, um, platelets, bacterial colonization, the beginning of a vegetation, another layer of fiber and played the deposition and thus grows a vegetation overtime layer after layer after layer. Once that vegetation occurs, it can then sort of have local destruction components, uh, perforations and abscesses. Or that vegetation, or at least the bacteria from that vegetation can break off on Get septic or other parabolic M bolic phenomenon. So this is typically the histology of the vegetation. It's fiber and and platelets, um, platelets here, shown in pink with a mixture of bacterial colonies, the sort of the blue elements. So that's an active, um, on. That would be an infective endocarditis with bacteria. So I'll show you this case as a a different case. So this is a personal long access on echo, you could see that the mitral valve is quite abnormal. If you see the inter mitral leaflet, when there's a clear abnormality on, it looks a bit like a hammer falling down. But there's also a fair bit of irregularity and thickening of the poster leaflet. This really does not demonstrate that oscillating future that I mentioned a moment ago in the other examples. But it is a mobile mass on two leaflets and noticeably on the flow surface of that valve. So what is that lesion? So that's the rule breaker that is fungal, uh, endocarditis. So it doesn't necessarily behave the way the bacteria does. Um, it has the mass, and it's on to leaf. But it just doesn't have that characteristic oscillation that most bacterial vegetation will something else to recognize. When a lesion gets really very large, it's often because it could be attached to a prosthetic material in the fashion. That's not obstructive s. Oh, this is a bacterial, uh, collection on a pacemaker lead on the right heart, and you can see elements. They're both within the ventricular side and the atrial side on their receded baseline. After the lead exchange, there's nothing there, So all of that material was attached to the prosthetic lead. And that's really what has thought to be fostering the increased incidence of Anna corn itis. It's the increased use of sort of indwelling longstanding prosthetic material, including, I really need devices the age forms of, you know, immuno suppression. So there is actually decade over decade of slow and steady increase in the incidence of endocarditis. This is one it's often a little harder to see by echo. Uh uh. This is a harmonic valve which, because of its air into your positioning, can be quite challenging. You see, at times you might just say that Well, this this is a very long linear. Something is that an artifact is a truly a mass. It is important to recognize that really destructive lesions have a consequence. And sometimes adding in the color shows that so this is a case which is really severe pulmonary insufficiency combined with something that looks like a vegetation on, with a little bit of history of an I V drug user and staph aureus bacteria. Mia. This is clearly a harmonic valve infective endocarditis. What is non infectious endocarditis? That's the term that comes up quite often. We don't see it very often, and we probably recognize it even less often. Um, but this is an example of one such case. This is a four chamber echocardiogram and you can see a little bit of thickening. An abnormality on the mitral leaflet violates perhaps some of the stuff we talked about in the beginning. It is if you look very closely and if I zoom doing on this, you might see that it's on both the flow surface and the ventricular surface. This is an example of a Libman Sacks. Uh oh. Canada. So they look quite different. Histological either Flat, uh, tan, spreading vegetation over the entire valve service and even down into the court, I s O A fungus could look like this, but if you have the history, that's an example of a Limon sacks. Endocarditis. So I think, really, the point of echo is to identify something happened something of normal mass. Look for the oscillating features we've talked about. It's very difficult to come up with a battery logic definition are diagnosis exclusively by echo. But one of the main roles of Echo is to look for complications of infectious endocarditis, and those have to be recognized both early and late. So this is an example of ah t showing both the aortic valve in the mitral valve. When you look closely on, I think my pointer just shows up here. At least on this monitor, you can see that there is, ah, wiggling sort of abnormality on the base of the poster or leaflet. But when you look closely just below that, there is a defect apparent, and is that really is an artifact again? One of the important tools for the sonography is to recognize is that if you're suspecting a defect test, test the suspicion with color on. When you add the color flow imaging, you can clearly see a defect. So this is M. R. That's originating not of the corporations own, but near the base of the leaflet. So that is very likely a perforation on the fact when the mitral leaflet is X planted. That's what it looks like. And it tends to build up with this little volcano and then ultimately purpose a hole through the middle s. So that's an example of ah, endocarditis, leaflet, perforation, Other thing to recognize. And then there's a focus on echocardiography. We tend to look only at the heart. Remember, on a T e? Certainly you can see the aorta. Uh, this is that same patient on dis was a bit of a surprise, sort of. Near the end of the t. The probe is being withdrawn evaluating the aorta, and you find this collection of activity. So this is several nasty things put together. This is a penetrating ulcer. This is a vegetation. And this is a dissecting flap all within the context of a psychotic aortic vegetation. So that's difficult to survive on, thankfully not seen very often. But remember, it does show you at least they ordered pathologies. And I'm sure this would be quite dramatic on C. T or C M. R. So what's so different about prosthetic valves? Um, really, it's this that they immediately they're all abnormal flow conditions. Doesn't matter how good the valve is. And it's low profile how big the areas or how low the radiant. Uh, it never truly recreates the smooth laminar flow of a normal valve covered with healthy and healthily. Um, so they're always prone to infection. Um, one of the challenges is in recent decades. The platter of all the options is fully expanded now from trans catheter valves and stateless valves and mechanical valves on multiple tissue valves. So it's, uh, it is very difficult, but incumbent upon images to know. What should the valve look like? What should the flow look like across this valve and to recognize early complications? So this is an echocardiogram again. A T in this case should play thankfully, and you can see that there is a mechanical valve in the aortic position. And as we always do, we sort of look very closely at that. Val, if you look at the mitral valve and there's some thickening, a little bit of lumpy bumpiness to it, but not necessarily a discreet lesion, however, we have to remember to look at everything in the image frame and slightly higher just up here, maybe two centimeters past the plane of the prosthetic aortic valve. There's this other wiggling mask. You could argue, whether it's oscillating or not, but it's certainly an abnormal collection right there. So that was felt to be a vegetation with specific cultures was identified as a fungal prosthetic valve into card itis. And in fact, this patient went for reduce surgery. And at the time of surgery, they found that there was just a little piece of sushi there from the tree Autumn E that was performed at the time of the aortic valve replacement. So this was a late complication. But of a surgical procedure Was the thinking that the time of the operation there was fungal seating of the aorta. It grabbed onto that little piece of suitor that was left on Then, over the course of several months grew into vegetation, um, necessitating surgery. So these are the important things to look for and all Not all vegetation of ah related to a prosthetic valves are actually on the prosthetic. Ralph, this is a different case. Uh, this is a bio prosthetic aortic valve in this patient, actually presented with frank stenosis, dystonia and sink api. Um, Grady INTs were very high leading to a T, and thankfully, we have a low threshold for evaluating prosthetic valve dysfunction with trying to salvage Alecko clearly abnormal situation with clear oscillation. So it continues toe wiggle long past the frames of the cardiac cycle, perhaps some para aortic thickening this could be difficult because some of that is normal in the early post out phase. At four months, this would be generally considered unusual. Thickening this'll was sufficiently abnormal. Patient was symptomatic. This patient went for reduce surgery and ultimately, this was diagnosed as no Cardia. Uh, endocarditis with very looks like a worm coming off off the aorta. Prosthesis eso All forms of endocarditis need to be considered. This was somebody who presented to our TV department, um, from the periphery. And they had had this question of this very unusual mass wiggling in the left atrium. Thats patient. A history of prior surgical micro repair was actually asymptomatic. No fevers and chills, no weight loss with a normal white count. But a very abnormal image with a little head scratching. And then ultimately, with some records review this was diagnosed is not a vegetation, but actually part of a surgical ring. This is a particular brand Owners in a tune ring. Uh, it's a fully flexible full ring, and it goes across the metro ball. But it has these long suitors that are meant to be tied almost like a belt on with several knots put together and for some reason, this inherent band was not tightened. The studio was left floating in the left atrium to confuse echocardiography is at another institution. Um, but just recognizing that not every wiggling masses, in fact, in endocarditis lesion and somebody who doesn't have a history that fits that so other issues around prosthetic valve endocarditis, Um, in general, on a bio prosthetic valve. Uh, the lesions will occur on the leaflets, but occasionally on the prosthetic cuff for struts as well on a mechanical valve. It's very difficult to get a lesion to adhere to the actual, highly mobile thinned pilot of carbon leaflets. So it tends not to be on the leaflets but rather supporting structure of the annular ring. This is such an example. This is an explain T view on the image on the right Here. You can see it's sort of prolapse ing down, and it's not hard to imagine that if the time they were just slightly different things would get caught in here on these can present either with stenosis or frank regurgitation on. Sometimes they don't present. If the remaining orifice is large enough that they can just come in with fevers and chills. Eso really of endocarditis truly is the great mimic er of many other disorders. But this is pretty classically on a T. What mechanical? Much a valve endocarditis will look like. Um, this could be thrombosis, but it's unusual to be thrown because it's a very high flow scenario. Um, particularly in Sinus rhythm. Possible, but less likely, bio prosthetic valve. Ah, shown here. So this is what I was mentioning on a bio prosthetic leaflet. You're more likely to have bacterial endocarditis at least form on the leaflets themselves. Less likely, but not impossible to form on the annular tissue. So this was a very unique case. This is generally a nauta Matic for surgery. Um, because the likelihood of successful decontamination for sterilization of this tissue is incredibly low, but not zero. And this is the case where it was not zero. This is a patient who had a very high risk for operation and almost a palliative approach. The decision was made to continue i v antibiotics, uh, indefinitely transitioning ultimately to oral antibiotics for life. But this valve could not come out because of other complex surgical considerations. But surprisingly, it's six weeks there was no visible, uh, vegetation anymore. So this is not a standard approach. This is not per guidelines. Surgery should have been first line, but when somebody can't have surgery, you do what you can. Eso this waas a clear clearance of the vegetation with parental antibiotics, but not a normalization of the valve. And if you look closely, you can see that this particular leaflet did not escape without some thickening. And now abnormal motion. You can see it here. It's a little bit abnormal, but it was mostly functional. But the three D did indicate ah consequence in terms of new pair of avatar defects. So again showing that the Angelus the sewing ring, uh, does not necessarily get away. And these air three distinct, perhaps even four distinct punked eight power valves or defects. In this case, they were small. They were not causing him. Allah assists. They did not require independent plugging or anything. Patient still has them. Eso That's the rare case of medical therapy of prosthetic valve endocarditis. Um, this is one again. A mitral valve three d t looking at a mechanical mitral valve. No lesions seen on the leaflets themselves or in the end of the ring patient very clearly had a history of endocarditis. Was culture positive was inhuman. And I am a compromise in the i c u Not doing well, very high. Pre test probability of endocarditis could not see any vegetation. But when you look closely, this area up here at sort of the upper quadrant would could easily be sort of written off. Well, we're catching a piece of the aorta. This is artifact. Well, this was, in fact, not artifact. This was a massive hole, uh, the Hisense of the upper third of this valve, Where and when they bring in the patient's prior history of having had this piece of tissue recreated from, ah, material called core matrix. Um, it was evident this had all been prosthetic material from the attempt that prior surgical correction of the center Cardiss. So that's sort of the culture negative with lots of antibiotics. Eso And this is sort of the one of the issues Is that to recognizing endocarditis, the cardiac crux for the fiber skeleton, that all of the, uh, your atrial ventricular valves in your semi lunar valves sort of passed through this tissue and This is the commonality and really endocarditis particularly, um, aggressive bacteria can can carve through and fist realizing almost any direction in this area very challenging for a cardiac surgeon to recreate these tissues. And often, if there's extensive involvement of the cardiac crux, there may not be a surgical option. This'd, ah, case of, ah, 75 year old woman who a bio prosthetic VR roughly two years ago. Aan den comes in with fevers and shells so appropriately that's a reasonable. That's a reasonable concern for endocarditis s. So this is a look at the valve, Um, and no, no obvious abnormalities here. It sounds like somebody else is trying to speak, But I'll keep going. Um, so pre test probability is Well, certainly concerning for under Kuraitis, this is an explain view through the valve on you can see here that there is probably a new issue here. This little mass there is is this the ultrasound shadow from the prosthetic material creates the data void that goes down from this part of prosthetic tissue. But this is concerning a little more history. In this case, there was severe prosthetic valve stenosis on Doppler evaluation. Grady INTs over 4 m, at least on some of the beats down here. So the idea. Well, let's repeat, let's go antibiotics for two months and repeat. And the thinking there is that they were treating that little mass. Um, s o great news. You don't see the mass? Um, you know, how is this a success now for this Bob Prosthetic aortic valve? Of course. When you look right here, you see that? That is now abnormal. So this is the beginnings of an abscess here, which is pretty common. So despite two months of parental antibiotics, a new abscessed forms eso This is an evolving prairie prosthetic abscess. You're not really gonna get away with any more months of parental antibiotics at this point. Um, things has proven itself refractory to antibiotic therapy. This requires surgery. Um, so send for a redo, A VR. And again, I'll show you back the very beginning. Echo. So this is when the mass was first identified. And in fact, if you look back at that study critically, you see that there is a little lucinschi right here. It's certainly less obvious. This is two months prior. Had that been recognized on diagnosed as an abscess. The two months would not have been wasted because this was a clear indication this patient needed surgery on. Perhaps Dr Omalu can talk about the other modalities that may have shown that abscess. I think it's evident on the T in retrospect, but it wasn't called at the time. So, you know, the issue around endocarditis and multiple ality imaging is just to recognize that this anatomy is all very close. Um, when you look at the mitral valve and the fiber, try Jones and how close it is to the aortic valve and the trick husband valve, and the harmonic valve does say it a little bit away. But the mitral trick, custom and the oryx really share the same real estate on with a nen vase of organism is very easy to get complications involving at least two and occasionally three of these valves. So just something to think about when you have a good quality trans esophageal echo. If you're looking down on the mitral valve from above, um, recognize it as the aortic valve pulses. It actually has this pulse across the interval. Verify Brosa, But the New York Metro curtain between the tri guns, and that's very normal. So that normal possibility is the aortic mitral interdependence. That's what you want to see and looking from below at Theo Vot. This is a very common area for both native and prosthetic valves to be involved in a way that requires surgery so again, that inter valve it or fibrosis exists right here. So it's not a lot of real estate for organisms to traverse because significant structural problems. So this is an example of an aortic root abscess. Eso we see that here has got that classic sort of not only thickening doesn't have a clear pocket of loosen see, but it's not homogenous that you can tell there's different collections of things, and this can just change and become vacillated and honey comb. Then it could get very, very obvious. But that's a that's a clear example of a root abscess by Echo. Um, this is a dreaded complication. Now, this is an aortic root, uh, thickening with actually that advanced into an LV abscess. So and then our abscess rupture. This is very difficult to survive. This actually exit the mile cardio eso. That's an extreme complication. You never want to see it get that far. This is more of a classic aortic root abscess. And this is where explain imaging could come in. This is fairly is about. This is about prosthetic aortic valve here with a short axis view on a simultaneous long access. You just to sort of show you that sort of heterogeneity of the tissues. You can almost imagine some puss in there and some inflamed tissue here. But the other thing to recognize that there is sort of a natural history starts with an abscess. The abscess could get quite large. This is a mechanical valve in the order position, and then you've got this intense pulsed utility. So the pulse utility exists because this is now open on the ventricular side. So it's my definition of pseudo aneurysm is a is a contained sacks, so it's contained on one side. Flow goes in, flow comes out. Therefore, this is pulse. It'll, uh, where to rupture on the other side. It would be a fistula. It will become less pulse. It'll because now it's just a conduit of flow. And if it continues or tra versus circumferential E, then that leads to the Hisense. So this is sort of an example, and you can put a pulse wave Doppler in here. You can put a Nemo down here. You can certainly evaluate this multiple ways, but this is a fairly gross example of that possibility. Whenever you see that sort of positivity, expect that to be a suitor Aneurysm here, as you can see the color close if you're watching the neck, it flows in and out of this. Contain chamber on indication for surgery. And this is the sort of the natural history example where it goes in and then out into the order again. So now you have a conduit around, and it becomes much less Pulse Hotel because it's not containing pressure anymore. It's just a conduit for flow. So that's sort of the natural history of what can happen with the root abscess. And this is an example of aortic root to an R a fistula. The real estate is close, and it can really go in any direction and give you all kinds of unusual connections, including your body defect on an acquired Ghobadi defect from the L V O. T. To the R. A is much more common than a congenital Ghobadi defect. So in summary, endocarditis is inflammation of the end of cardio usually involves the valves, but other structures could be affected, including accepting the court I into cardiac devices. Remember the definition of the prototypical lesion, the vegetation that's fiber in its platelets? It's the organisms themselves, and it's inflammatory cells. On Echo is the mainstay of diagnosis and treatment. But clearly there are times women need more data. We need data outside of the heart or were unique sort of markers within the heart. And for that conversational turn you over to my colleague Dr Almallah. Thank you, Steve. That was an excellent overview of the role of eco Onda card itis. Andi, can I have my slides up? So while we were waiting from my slides to come up just reminding everybody that you can text debated Thio 376 or seven and then you can text us our questions and we're streaming live on multiple social media platforms, including Twitter and Facebook and YouTube. Okay, so we had an excellent talk by Dr Little about the roll off econ and the card itis. So now I have three modalities to cover in the same time. There is no doubt that Echo is always first in the card itis, but unfortunately, with the complexity of patients we're seeing, it's not always last when you probably need to resort one or time or the other for other imaging modalities to confirm or gather more information for planning the intervention or therapy for these patients. So I'm going to start with C T on. Would you look in city? Sometimes it could be an incidental findings and some patients, but as you see here, we can see a vegetation. Obviously, if you're going to be able to acquire high quality images, you need systems that allow you toe acquire it with high resolutions. You need the 64 slice or higher. But more importantly, the temporal resolution to be able to capture the smaller devices is a smaller vegetation. Looking also, you can look at complications including something similar to what Steve was just showing looking at the Sudan aneurysms or even the fistulas that you see here, where it's full with contrast and it's coming down to the V here. The bigger the vegetation, obviously the easier to image with city, sometimes it iss smaller. It may not be able to capture it very well. Andi, if you're looking for this device, this type off pathologies you need to be to image them using retrospective, getting together the full cardiac cycle to capture them with these images in high resolution. So, in looking insensitivities, obviously these are by a Siri's because not every patient is going to get a transference official echo and city. So these are pre selected populations. But among these populations, sensitivity is very high for city, and specificity is also high. If you use city with operative findings of the gold standard now, you're gonna have a higher sense. Specificity on in terms off vegetation size and mobility, the accuracy was pretty high. Now what is the advantage off C. T or the advantages off city compared to tea, especially in the current Iran, the covered 19 where we try toe limit use off the in patients that we don't know they're covered status obviously have higher special solution. The temporal resolution is still much better with the We have volumetric assessment so we can take the images and look at them after a slice it and dice a different way. However, with C. T. We don't have the floor assessment, which is still best with E. Obviously, if the patient has in its official pathology, we prefer city patients with renal failure or contrast. Allergy T is the preferred one if you're looking for other pathologies like especially in covered patients, where you have long pathologies and other city would be preferred compared. Toa patients who are now cannot be mobilized to the city unit, where t can be portable in the i c e O. On now, this is with covert 19 considerations. You need less personal protection equipments with city versus the infectious risk maybe a little bit higher with the on This is these are the different pathologies where CT can look and compared to T. And both of them actually have good accuracy, looking at different vegetation, looking at complications, looking at the hastens and Sudan aneurysms and also looking at panels thrown by calcification city advantages, primarily to look at the extra cardiac findings and also for surgical planning. This is a patient, for example, who has a pseudo aneurysm. The valve is the hist here, and you can see here these are still images. I'll show you some Sydney images later. This is a patient where you have some complications where you look at soda aneurysms and you can see here the pseudo aneurysm there. We also look at vegetation and try to compare them from Panis or from from by And for that we use on city what we call the household unit. For those of you who don't use cardiac city, the reference there is actually for Hansel Genet. Water is kind off where the references at zero air has like minus 1000. Fat is usually in the negative between minus 5200. Now, if you go toe blood now we're getting to 45 to 65 hematoma are thrown by could be from 40 to 90. So anything above 90 it's unlikely to be a vegetation or thrown by in these patients. Here, you can see this patient has, like, multiple thrown by with this high resolution city. This is calcium. Here in the vote. Now, the Panis would be much higher than 1 45 thrown by usually less than 90. If you look at this bio prosthetic valve, you can also look at them there is thrown by their If there is, If you do a retrospective getting and you cannot assess it fully by echocardiography, you're gonna be able to assess the opening. And if there is the generation of the valve on top of the card itis on this is actually a patient. So who has actually developed the history? You can see some rocking movement off the valve itself. You may not need T for that, but you may not need city for that. But sometimes you're getting city for other indications. Mainly sometimes assessment of the corners prior to surgery. This is a nice study just published recently in circulation image ing, where they looked at 75 patients who had both c t on three d t. Within three days. Most of the patients had metal valve pathologies, but still half of them had aortic valve pathologies. I'll show you some of the cases where the there was agreement between the two modalities off here, for example, there is an interior Michael Leaflet perforation where you can see it very nicely on city, but also you can see it very nicely on T E and three D Yeah, here is patient with infective endocarditis and soda aneurysms. Also very nicely seen in this by patient with bicuspid aortic valve. You can see very nicely on C t, but also well appreciated on t. So you may not need both modalities to confirm it unless there is some other difficulty on this is, for example, a fiesty and perforation where there is actually sub VSD complicating the endocarditis and you can see the nice flow by echocardiography. However, there are times where things may not be as easy to call. This is, for example, by city a clear vision abscess information there on by Echo, for example. Here it was not very clear, according to the authors off this paper. So we're looking at the overall accuracy for detecting detection of vegetation. SETI does very well when the vegetation is more than 10 millimeters detected nearly 90% of the vegetation. Now, once it goes below 10 millimeter Onley, 52% of vegetation is were detected by CT. Now, when we go toe the other complications there was nearly almost more than 90% agreement or even more than 95% agreement. Looking at the perforation aneurysm. The abscesses, pseudo aneurysm, the fist allies and prosthetic valves hastens. I just want to bring up the the other valves and the card itis because this is where sometimes may not be easy to assess by echo. If there is, uh, the problem from visualizing inside the valve, this is a patient off mind that unfortunately had a tavern valve. This is her CT after the valve and she was doing fine on she came in with new Grady INTs And you can see the whole valve waas She had fever and, uh, positive blood cultures. In addition to that on c t, she couldn't get E because she was very sick. We did the quick city and we see the vegetation on almost complete obstruction off the valve on this patient, unfortunately, passed away like 12 hours after the city. Um on you can see here these patients from this paper Rajan Jama The two year mortality rate among those patient with tavern and the card itis was nearly 67%. So if once they develop in the card itis, the mortality is very high among this patient population, obviously they are already sick. That was probably at the time of the pop this publication. That's why they got the tavern evolve to start with. We can also look at extra cardiac involvement, for example, like in this patient who has a vegetation. But also there is this clinic and far, and you can also look at extra cardiac like looking from brain abscess. Ease looking at splenic in Fox Adrenaline Fox and also aortic Micah Tick aneurysm. So with C. T. If you're looking for these, you're going to get good assessment off the valve or the site off infection, but also for other extra cardiac complications. And finally, among those patients that are going for surgery. Most often you need a coronary assessment and cardiac CT can give you that also as well, so moving on to cardiac camera. It also allows you to assess vegetation. Ziff, they are big enough because small vegetation is maybe not well visualized by CMR because off the averaging off multiple beats. But I think see Amar is very useful in the assessment, not in the very acute phase, because these patients are usually sick and if they have abscesses or other, they may not tolerate the procedure but among those patients who have healed in the card itis but have complications from that. Like I article sufficiency or mitral insufficiency, CMR would be the best tool to assess the regurgitation. Get the volumes if there is a flail leaflet and also help in aiding the in making the decision for the therapy therapeutic options for these patients going to move on now to pet on with PET It had made a lot off increase utilization for cardio for endocarditis. If you look in the literature, there is almost a paper every few weeks about this topic, and it's an important topic, especially with the increase utilization off hardware and the heart on. This is, for example, a patient who had a valve implanted three years ago, now coming with symptoms suggestive off endocarditis. You can see significant F DJ optic around the valve. So what type of protocol? I just want to take a few minutes toe, clarify the protocol because it's very important to prepare these patients well. And if you are aiming toe, look at the valve. So anything within the heart other than like the uh if you're not looking like, for example, at the pacemaker pocket. If you're looking at the valve itself, the patient should follow this preparation. The way we do it is that we usually tell them the day before there should be No. We try to suppress the my Godel glucose uptake. So we would like toa have low carbohydrate or preferably no carbohydrate diet and fasting more than 12 hours. So this is not a procedure at this time that we can order and to get done immediately on usually with all patients, have high carbohydrate high fat diet but should not have any carbohydrates When they come to the lab, we usually if there is no contra indication to give them happen, and we try to give them happen. We wait for 15 minutes, we give the f. D. G does with another 60 minutes and then image them. So the preparation is extremely important. Because if I'm looking at the valve and you can see here the heart like Lucas off, I give f d g. The heart is gonna light up without any cardiac preparation, and it might. It might limit my ability to see the valve very well or sometimes might cause some false interpretation. So this is how enormous study would look like No f d g optic on. This is how a positive study would look like, for example, for this valve where there is significant F D G uptake around the valve in this patient, where they bring abscess in there and there's a whole spectrum off. Findings can be just more localized to one area. It can be very diffused. It depends on the extent of disease and how bad the complication is at the time off image ing, for example, this patient has not only the valve involved but also the aorta, and there is even an aortic root abscess. But there is also the ascending aortic root that's ascending aorta that's involved, and you can see all these abscesses at the level of the prosthetic valve on. This is another patient who has much less involvement. But still prosthetic valve in the card itis was significant F d g update around it. This is a patient we had a few weeks ago where you can clearly see that there is an abscess echo waas kind off concerning, but not definitive. So we did see ta and again if the patient has normal kidney function. We prefer to do a C full city A with contrast to be able to fuse both of them and have better localization. And in this patient there is an abscess on C. T. A. And this is clearly the focus off infection for this patient on. In fact, there were two ecstasies which were confirmed by surgery. If you look in here, we can also look in specific at the valve itself. And you can see touring ecstasies and one less subject. It can also help in detection off. Sorry, Tavern valve endocarditis on this is like it will help you localize where the endocarditis is. So this is an a patient. This is from the European Heart Journal and clearly showing that there is a f DJ optic. But much higher than the level off the annular thistle is an important study that Waas published just in the past 12 month. This is coming from the European Society of Cardiology. The E S e v i. It's called the Euro and the card itis registry. It's an international registry on. I was lucky to participate in it. It included 3000 patients more than 3000 patients with endocarditis. Ah, lot of them were native valve endocarditis, but there were prosthetic valve and the card itis and also cardiac devices. This looked at the natural history and also educated us on what's going on right now in terms off image ing these patients. So in terms of image, ing still echoes the primary modality for imaging. But you can see here that trans esophageal echoes required in certain times. Pat was also utilized less often in native vows. Appropriately so, but more often in prosthetic on cardiac devices on City and Marie were also utilized in these patients. I'll show you some of the findings that primarily that cardiac devices Sorry, pet, uh, had a good sensitivity and prosthetic valves, but less in native valves or in cardiac devices. And I'll show you some more data about this on this is real life data that was interpreted at the site. Not like in a core lab. It is very important to recognize that cardiac that cardiac pattern is not the test of choice at this time, at least for native of endocarditis. It can miss it completely. As you see, for example, in this patient where there is a clear and the card itis and vegetation, and it was not picked up for unclear reasons. So they're obviously there are limitations for Pet City. It can be false, positive and some patients, and we'll discuss why that could be ah, lot of it could be from poor preparation. If it is your detecting my cardinal uptake rather than just in the card itis it could be related to the If there is a graft by a glue might take up some uptake prosthetic valve from bosses in the acute phase. Might take also F D G and also early after surgery, which has been a item for debate. But I'll show you also some data to help. So here I am showing you four patients. All four patients have different SUVs, which is how much up take off F d g. You see around it on some of them have very little uptick. As you see here, this patient has significant uptick, and all of these patients do not have the card itis except for this one. So this is the only patients so usually little uptake is more related to inflammation. the more uptake you see the more related toe infection, but also so sometimes maybe a little bit more difficult to identify if it is infection. Infection versus inflammation here is, like more concerning for infection. Thistle is a patient. Once you look here, now you see a lot off uptake in the mid Eocene. Um on this is the patient toe have actually allergy to the glue that they use and surgery, and you see significant inflammation rather than infection in this patient. So he had allergy to the surgical glue. But there is usually the spectrum, so inflammation would be more diffused. Less uptake on the infection is usually more focal follows like, usually less diffuse and usually much more intense compared to the other inflammations that you see here. This is a nice study where they brought patients who had surgery, looked at them at one month, six month and 12 month, and they showed that there is some for very low uptake in these patients. If you quantify it, it is almost did not change over 12 months or even over a year, suggest that potentially this little uptake, you can go over and it's going to stay with time. And if you haven't the card itis you probably need toe have very strong uptake on the very highest service and these patients. So even if it is early after surgery, if the patient has no uptake, that is reassuring. If there is significant uptake, then you can still diagnose. And the card itis in this time obviously a common cause off false negatives. False positive story. False negative studies is the use of antibiotics off a patient comes into the lab three or five weeks after antibiotic use. There is much less and much less F DJ optic. This is a patient who had their f d g in the beginning on, then later on. So if you image the patient just after their antibiotic, you're not going to detect the the ftt optic and this in these patients on Daz in C. T. You can also look for incidental uptake and other organs. And if there is, like osteomyelitis correspondingly, disc itis, as you see in this patient on these were actually most often seen about, like to be clinically 11th in about 15% of patients. Whenever I give a study like this I always asked about white blood cell counts versus F D. G. Shall we use white blood cell counts? Because prior to the widespread use off pet F D G people were using what will tag bluffs, white Lessel scans for that. It is a less off a sensitivity. And this is a case I found on the literature coming from Dr Decision from Maryland, where they looked at this patient. They had F d. G on Dwight Blood Cell, where there's significant f d g uptake in this patient with infective endocarditis. But there was no uptake on the white blood cell, so it is sometimes usually it's concordant. But there is higher sensitivity overall for F d g path in these patients gonna move on a little bit of pacemaker infections. We can look at pockets, we can look at Leeds on, we can follow them up. It's very important with the more metal you have, you have to look at the non attenuation corrected in addition to the if you wanna look at the attenuation corrected images, you can see here the pocket infection in this patient that have been this paper just came out 8 p.m. Yesterday on circulation imaging website on This is a meta analysis. Off pattern endocarditis 26 studies 1358 patients, nearly 34 40% of them had endocarditis. The sensitivities about on overall waas 74% specificity was in the eighties. However, once we start, this is all endocarditis, 88% specific, 74% sensitive. However, once we start to break them down, we can see that Ah, lot of the decrease sensitivity is coming from the native valves. But the specificity is very high in these patients when you look at specifically at prosthetic valves, sensitivity was 86%. Specificity was 84% on for cardiac devices, 72% sensitive, 83% specific. So it's much higher yield in these patients with prosthetic valves than native valves. I want to finish up quickly with valve odds, because this is an area where it might be difficult to look for infection using echo or even city, with all the blooming from the metal that we see. So with valves you can get it from different points. You can get it from the entry point. You can get it from the subcutaneous drive path. You can get it from the pump itself or from the outflow track on for this. It does have management on prognostic implications where the infection is. It's not important only to know where is it but also where the location is and the extent so. This is, for example, patient tohave the subcutaneous to show, but not the pump itself. This is, for example, a patient where it is in the pacemaker. This is in the outflow track off the al bod. This is, for example, again in the outflow track off the Alva did. You can see it there and again. It's very important to look at the non attenuation correction for these patients. This is that the entry point that's the relatively the easiest to treat. This is another patient where it is in the subcutaneous path. This is in both the subcutaneous path, but also in the pocket off the pump, and this is the most concerning in these patients on. You can also look for other inv local involvement in the chest, like in the thoracic chest. And otherwise, Andi, obviously, the more central the infection ists off the pump is infected. The worse the outcome, as you see in this Siri's or in this other cities also the intensity of the infection. So, looking at the standard uptake, the more F d G uptake is the worse the outcome of these patients compared to the last F DJ optic population. So where do the guidelines stand in regards to pet. So if you go to the most recent guidelines that we have in the US, you put in pet and this and the endocarditis guidelines and you don't see any, the world doesn't come. You put FDD. Nothing comes in the European guidelines. At least you'll find something suggestive that now the major criteria is positive image ing. Sorry, positive blood culture, but also a positive image ing on positive image ing. Obviously, if you have it by echocardiography. But now F D g pet is considered among those positive, uh, positive criteria for white lots for the card itis. This is the algorithm specifically from the guidelines where European guidelines you're starting with echo. But if you're getting you're still not having the final answer, you're gonna go ahead and move on to City and pat, so to summarize up what we have for prosthetic valves. F d g Pet does help for early detection of valve infection, extra cardiac infections or surf emboli City will help you with the late detection of structural complications and t obviously establish the diagnosis but also detection off the structural complications for cardiac devices. F d G allows for early detection, off pocket lead infection, extra cardiac infection. City will also help detection off structural complications, abscesses and others. And also tea helps for lead vegetation. And finally, for al vod, F d. G is for the early detection and differentiation off central versus peripheral Alvalade infection. City comes next would late detection off infection sign and he may be very limited in these patients. With this, I'm going to stop and see if we have questions. All right. Thank you, Dr Alam. Ella, look over here at the questions that have come in. There's one. I think you can probably see that as well mentioned that vegetation can contain inflammatory cells. Uh, correct assumption that the actual amount of leukocyte infiltration in a vegetation is often limited compared to a pair of Alvin or extension. That makes sense. Um, vegetation. You know can only get so big. I don't think a lot of that is actual inflammation in the way that we think. A pair of Alberta tissue. Um, I think pathologist, what might dissect that answer in detail for quite some time. But I think in general I would agree with that assumption that there's not a huge amount of inflammatory tissue and vegetation, but there are some. Do you have any other questions? Nothing on Po V. I think we're also in Zoom. Yeah, I've got a question. So can you hear me? Is that Dr Shaw? The one and only Dr Shaw? Yeah. You can hear me. Yeah. So one very nice presentation, guys s e. Let me ask. Let me challenge you a little bit. Why? Why do you think it is that the native valves? This sensitivity is not as good for Pat, Is it? Because again, just the burn it or the amount of white blood cells may be lower than a pair of Alvin or abscess or just kind of curious. What your thoughts are is why that's the case. May be a question in case it wasn't s. So the question is looking at why pet is not sensitive and native valve and the card itis compared to other prosthetic and method on. There are multiple theories in the literature. It could be just a burden itself or the type of blood cells that usually attracted. And these type of infections toe the area off abscess information. So I'm not aware off any definitive answer, but it's been well recognized, and we'll seen across the front literatures and even in the multi center registry. So that's right. The real answer. Why it's probably more has to do because we're imaging white blood cells, whether we're attracting certain types of blood cells or certain finna types of blood cells, or whether blood cells release different chemicals that will increase inflammation. And these type off abscesses is not very clear to me. But again, for from a clinical standpoint is very helpful that if we do it and if it is negative, at least from the meta analysis that has high negative specificities, so I'm probably good negative predictive value. But if it is spot, if it is negative, uh, does not. If you see it, it's there. If you don't see it, that doesn't rule it out completely. So I just want to say that I commend you non echo Emma, my imagers for keeping track of, ah, lot of things, including the alphabet soup of M d c T c T pat CMR SUV, which was a new one I heard today. I thought I knew what that meant, but that means something different apparently. Um, but really, a lot of the innovation in the field or the concern of endocarditis is in the in the imaging, and most of it is not echo at the moment. Echo has to sort of keep up with all the various valves and iterations of valves. But the echo techniques other than the addition of three D are pretty standard at this point. But the innovation and the image ing outside of Echo is really quite impressive. I Well, I think we're at time. Then if there's no other questions, well, thank everybody for your attention, and we hope to see you at the next M of my conference. Thank you.