Improvement in the Diagnosis of Abscesses Associated with Endocarditis by Transesophageal Echocardiography
Open accessAbstract
BACKGROUND: Echocardiography is recognized as the method of choice for the noninvasive detection of valvular vegetations in patients with infective endocarditis, with transesophageal echocardiography being more accurate than transthoracic echocardiography. The diagnosis of associated abscesses by transthoracic echocardiography is difficult or even impossible in many cases, however, and it is not known whether transesophageal echocardiography is any better. METHODS: To determine the value of transesophageal echocardiography in the detection of abscesses associated with endocarditis, we studied prospectively by two-dimensional transthoracic and transesophageal echocardiography 118 consecutive patients with infective endocarditis of 137 native or prosthetic valves that was documented during surgery or at autopsy. RESULTS: During surgery or at autopsy, 44 patients (37.3 percent) had a total of 46 definite regions of abscess. Abscesses were more frequent in aortic-valve endocarditis than in infections of other valves, and the infecting organism was more often staphylococcus (52.3 percent of cases) in patients with abscesses than in those without abscesses (16.2 percent). The hospital mortality rate was 22.7 percent in patients with abscesses, as compared with 13.5 percent in patients without abscesses. Whereas transthoracic echocardiography identified only 13 of the 46 areas of abscess, the transesophageal approach allowed the detection of 40 regions (P less than 0.001). Sensitivity and specificity for the detection of abscesses associated with endocarditis were 28.3 and 98.6 percent, respectively, for transthoracic echocardiography and 87.0 and 94.6 percent for transesophageal echocardiography; positive and negative predictive values were 92.9 and 68.9 percent, respectively, for the transthoracic approach and 90.9 and 92.1 percent for the transesophageal approach. Variation between observers was 3.4 percent for transthoracic and 4.2 percent for transesophageal echocardiography. CONCLUSIONS: The data indicate that transesophageal echocardiography leads to a significant improvement in the diagnosis of abscesses associated with endocarditis. The technique facilitates the identification of patients with endocarditis who have an increased risk of death and permits earlier treatment.
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Even transesophageal echocardiography may miss initial perivalvular abscesses, particularly when the study is performed early in the patient's illness.
“Even TEE may miss initial perivalvular abscesses, particularly when the study is performed early in the patient's illness.54”
From Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association (2015) · cites this paper as [54]
The Transesophageal Echocardiography section (p. 2) reports that TEE detected 40 of 46 abscesses, supporting that it can miss some. The Limitations of the Study (p. 5) describes a small abscess that can be missed because of acoustic shadowing, but neither passage links missed abscesses to studies performed early in the patient's illness. (LLM, conf=0.88)
Experimental — accuracy not yet measuredTEE dramatically improves the sensitivity for defining periannular extension of IE (76% to 100%) while retaining excellent specificity (95%) and positive and negative predictive values (87% and 89%, respectively).
“TEE dramatically improves the sensitivity for defining periannular extension of IE (76% to 100%) while retaining excellent specificity (95%) and positive and negative predictive values (87% and 89%, respectively).54,307”
From Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association (2015) · cites this paper as [54]
The Transesophageal Echocardiography section (p. 2) reports that TEE detected more endocarditis-associated abscesses than transthoracic echocardiography, with specificity of 94.6%—approximately the claimed 95%. It reports TEE sensitivity of 87%, positive predictive value of 90.9%, and negative predictive value of 92.1%, not the claimed sensitivity range of 76% to 100% and predictive values of 87% and 89%. (LLM, conf=0.90)
Experimental — accuracy not yet measured
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- Authors
- Daniel, W. G., Mügge, A., Martin, R. P., Lindert, O., Hausmann, D., Nonnast-Daniel, B., Laas, J., & Lichtlen, P. R.
- Affiliations
- Medizinische Hochschule Hannover (DE)
- Emory University (US)
- Venue
- New England Journal of Medicine
- Publisher
- Massachusetts Medical Society
- Published
- 1991-03-21
- Volume
- 324
- Issue
- 12
- Pages
- 795-800
- ISSN
- 0028-4793 (ISSN-L)
- 1533-4406
- OpenAlex
- W2330574484
- Cited by
- 723
- References
- 32
- Citations by year
- 2026: 6 · 2025: 5 · 2024: 11 · 2023: 16 · 2022: 8 · 2021: 22 · 2020: 11 · 2019: 23 · 2018: 16 · 2017: 14 · 2016: 24 · 2015: 22 · 2014: 19 · 2013: 20 · 2012: 21
- FWCI
- 30.95
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- New England Journal of Medicine (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Epidemiology › Infective Endocarditis Diagnosis and Management
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Valve Diseases and Treatments
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Streptococcal Infections and Treatments
- Keywords
- infective endocarditis, transesophageal echocardiography, transthoracic echocardiography, abscess detection, aortic valve endocarditis, Staphylococcus, sensitivity and specificity, in-hospital mortality, observer variability, valvular vegetations, autopsy confirmation, surgical diagnosis, non-invasive diagnosis
- MeSH terms
- Abscess, Adolescent, Adult, Aged, Aortic Valve, Echocardiography, Endocarditis, Female, Heart Valve Diseases, Heart Valve Prosthesis, Humans, Male, Middle Aged, Predictive Value of Tests, Prospective Studies, Sensitivity and Specificity, Staphylococcal Infections
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