Andersons pediatric cardiology 1486

■Paravalvarcomplications,includingaortic
abscess34,35
■Intrastentvegetations
■PTE
■Systemicperipheralthromboembolism,including
cerebral
■Subarachnoidhemorrhageinrupturedmycotic
aneurysms
Itisreasonabletoscreenpatientswithright-sidedIEforpossiblePTEpriorto
operation.
SerialCTimagesshowprogressionofdiseaseandareaninvaluabletoolto
guidemanagementandarebecomingmorewidelyused.
TherearecurrentlynolargecomprehensivestudiesfortheuseofCTin
pediatricIE,andthisisafieldoffutureinterest.

PositronEmissionTomography–Computed
Tomography
Positronemissiontomography(PET)/CTisanothernewimagingstrategy
includedinthe2015EuropeanSocietyofCardiology(ESC)IEdiagnostic
criteria.1Itisanuclearimagingmethodthatuses18F-fluorodeoxyglucose(18FFDG)andcapitalizesonthefactthatinfectiousandinflammatoryfociare
metabolicallyactiveandhavehigheruptakeof18F-FDG.Theadditionof18FFDGPET/CTasamajorcriterionincreasesthesensitivityofthemodifiedDuke
scorefrom70%upto97%forprostheticvalveendocarditis(PVE)and
implantablecardiacelectricaldevice–relatedIE(ICED-IE).38
PET/CThasgreataddedvaluefordiagnosingIEinthecaseofunconvincing
outcomeoftherestoftheimaginginsuspectedIE,especiallyinprostheticvalve
IEorcardiacdevice–relatedIE.
TheroleofPET/CTforthepreviouslymentionedindicationshasbeen
characterized36,37andconfirmedinrecentlargerstudies.38–41Theroleof
PET/CTinpediatriccardiacpatientsandpatientswithcongenitalheartdefectsin

generalhasrecentlybeenreviewed.42
TherearecurrentlynolargecomprehensivestudiesfortheuseofPET/CTin
pediatricIE,andthisisafieldoffutureinterest.

BrainImaging
PatientswithIEandneurologicsymptomsshouldundergobrainimaging,
magneticresonanceimaging(MRI),or,ifnotpossible,CT.BrainMRIhasgreat
significanceforvisualizingthecerebralcomplicationsofIE.43
Itisreasonabletoscreenpatientswithleft-sidedIEforpossiblebrain
involvementpriortooperation.7
Serialbrainimagingisexcellenttoshowwhetherthereisanincreasing
numberofmycoticaneurysmsandotherchangesthatwillindicateearlysurgery.


Diagnosis
ThediagnosisofIEstillusesthemodifiedDukecriteria.11Underthecurrent
revision,followingtheadvancesinimaging,theESC2015guidelineshave
addedthepositiveCTandthePET/CTtothemajorcriteriaunderthelistof
positiveimagingmodalities.Thecurrentlyusedversionofthediagnosticcriteria
withrevisionsandrecentamendmentsisshowninTable56.2.
Table56.2
RevisedDukeDiagnosticCriteriaforInfectiveEndocarditisWith
Amendments
MajorCriteria
1.Bloodculture(BC)positiveforIE
■TypicalmicroorganismconsistentwithIEfrom2
separateBC:
■Viridans-groupstreptococci
■Streptococcusbovis
■HACEKgroup

■Staphylococcusaureus
■Community-acquiredEnterococci,intheabsenceof
aprimaryfocus
■MicroorganismsconsistentwithIEfrompersistently
positiveBCdefinedas:
■TwopositiveBCofbloodsamplesdrawn>12hours
apart,or
■Allof3oramajorityof4separateBCofblood
(withfirstandlastsampledrawn1hourapart)
■SinglepositiveBCforCoxiellaburnetiiofphaseI
IgGantibodytiter>1:800
2.ImagingpositiveforIE
■Positiveechocardiogram:
■Vegetation(oscillatingintracardiacmassonvalveor
supportingstructures,inthepathofregurgitantjets,
oronimplantedmaterialintheabsenceofan
alternativeanatomicexplanation)
■Valvarperforation/aneurysm,chordalrupture(new
valvarregurgitation)
■Abscess,pseudoaneurysm,intracardiacfistula
■Newpartialdehiscenceofprostheticvalve
■PositivecardiacCT:
■Paravalvarlesions,abscess
■Intraluminalfillingdefect
■Positivenuclearimaging:
■Abnormalactivitydetectedon18F-FDGPET/CTor
radiolabeledleukocytesSPECTaroundthesiteof
prostheticvalve(onlyiftheprosthesiswas

MinorCriteria

1.Predisposingfactor:knowncardiaclesion,
recreationaldruginjection
2.Fever>38°C
3.Evidenceofembolism:pulmonary
thromboembolism,peripheralandcerebral
embolism,mycoticaneurysms,Janeway
lesions,conjunctivalhemorrhages
4.Immunologicproblems:glomerulonephritis,
Oslernodes
5.Positivebloodculture(thatdoesnotmeeta
majorcriterion)