Introduction
PHV endocarditis
Major criteria
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1. Blood cultures positive
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*Typical microorganism from two separate blood cultures: |
Streptococcus viridans, Streptococcus bovis, HACEK Group, Staphylococcus aureus; community-acquired enterococci, in absence of a primary focus or |
*Microorganism from persistently positive blood cultures: |
At least two positive blood cultures drawn > 12 h apart or all of three or a majority of ≥ four separate cultures positive with the first and last drawn at least 1 h apart or |
*Single positive blood culture for Coxiella burnetii or phase 1 IgG antibody titre > 1:800 |
2. Imaging
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*Echocardiography: positive signs for infective endocarditis (vegetation, leaflet perforation, abscess, new partial dehiscence of the PHV) |
*Molecular imaging (FDG−PET or leucocyte scan): for the detection of periannular infiltration |
*Computed tomography: for the detection of periannular infiltration and/or vegetations |
Minor criteria
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*Predisposition: predisposing heart condition such as PHV or injection drug use |
*Fever: temperature > 38 ℃ |
*Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial haemorrhages, Janeway lesions |
*Immunological phenomena: glomeronephritis, Osler’s nodes, Roth’s spots, rheumatoid factor |
*Microbiological evidence: positive blood culture that does not meet the major criterion |
Definite diagnosis of infective endocarditis
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2 major criteria |
1 major and 3 minor criteria |
5 minor criteria |
Possible diagnosis of infective endocarditis
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1 major and 1 minor criteria |
3 minor criteria |
Novel imaging strategies for PHV endocarditis
Multidetector-row computed tomography
FDG-PET
Leucocyte scan
Three-dimensional TEE
Cardiac magnetic resonance imaging
Proposed imaging strategy
Concomitant coronary angiography
PHV obstruction
Pannus: fluoroscopy predictors
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Thrombus: fluoroscopy predictors
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Leaflet restriction mostly present | Leaflet restriction always present |
Leaflet restriction may be absent | Total occlusion of one leaflet and normal opening of the other leaflet (in bileaflet PHVs) |
Pannus: echo predictors
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Thrombus: echo predictors
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Slow increase gradients/decrease EOA | Sudden increase gradient/decrease EOA |
Absent/small mass on inflow side of PHV | Present mass/large mass on inflow + outflow side of PHV |
Hard echo density | Soft echo density |
Pannus: MDCT predictors
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Thrombus: MDCT predictors
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Hypodense mass on inflow side PHV | Hypodense mass on inflow and outflow side PHV |
Mass anatomy: (semi)circular configuration curved along the valve ring | Mass anatomy: irregular shape, directly attached to the leaflets/hinge points |