Infective endocarditis: echo and ECG helped diagnose perivalvular abscesses.

Clinical bottom line (level 2b)

  1. 2-D echocardiography and ECG were both useful at ruling in perivalvular abscesses in patients with infective endocarditis, but neither could safely exclude it.
Aguado et al: Chest 1993; 104: 88-93
Expires July 2003

The study

Setting: university teaching hospital, Spain

56 patients (aged range 18 to 77 years; mean 48, 95% male) 36 patients with proven perivalvular abscesses associated with infective endocarditis compared with 20 patients with infective endocarditis chosen at random in whom myocardial abscesses had not been demonstrated at surgery

Independent blinded reference standard, applied in all patients from a consecutive inappropriate spectrum.
Reference standard:
  • surgery or autopsy- region of necrosis containing purulent material and penetrating into the paravalvular annulus or myocardium with cavity formation, or myocytic aneurysm of the aortic root
Diagnostic test: 1. transthoracic 2-D echocardiography- positive if any of:
  • presence of a definite region of reduces echo density, excessive thickness images or echolucent cavities within the valvular annulus or adjacent myocardial structures in the setting of valvular infection
  • aorto-left ventricular discontinuity
  • a mycotic aneurysm of the aortic root
2. ECG- positive if atrioventricular, and/or bundle branch or fascicular blocks suggesting an abscess

The evidence


diagnostic test perivalvular abscesses no abscesses LR+
(95% CI)		 LR-
(95% CI)
echo positive 29 3 5.4
(1.9 to 15) 		0.23
(0.11 to 0.46)
ECG positive 18 2 4.5
(1.2 to 17) 		0.61
(0.45 to 0.84)
total 36 20

  • The aortic valve was involved in 80% cases, and the mitral valve in 40% of cases.
  • The commonest infective organisms were Staph aureus (23%), coagulase-negative staphylococci (20%) and streptococci (20%).

Comments

  1. Pre-test and post-test probability are meaningless in this study, since the proportion of controls was pre-selected.
  2. The diagnosis of perivalvular abscess is important as it should lead to prompt surgery, to reduce the mortality rate.

Citation

  1. Aguado JM, et al: Perivalvular abscesses associated with endocarditis: clinical features and diagnostic accuracy of two-dimensional echocardiography. Chest 1993; 104: 88-93
Search Terms: infective, endocarditis and echocardiography in Medline
Contributor: Sumit Dhingra, Carl Heneghan and Chris Ball, July 2000
Reviewer: William Rhoton

Clinical Question.
Patient infective endocarditis
Intervention or Exposure echocardiography and ECG
Outcome diagnosis of perivalvular abscess