Best Practices for Imaging Cardiac Device-Related Infections and Endocarditis: A JACC: Cardiovascular Imaging Expert
Vasken Dilsizian1, Ricardo P J Budde2, Wengen Chen1
1Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA.
Insights
Diagnosing cardiac device infections and pinpointing the infection site are challenging. Fluorodeoxyglucose positron emission tomography with computed tomography (FDG PET/CT) shows promise for early detection, guiding better patient management.
Area of Science:
- Cardiology
- Nuclear Medicine
- Radiology
Background:
- Cardiac device infections pose diagnostic challenges, particularly in localizing the infection site.
- Echocardiography is standard but can be inconclusive in complex cases.
- Emerging imaging techniques offer potential for improved detection and management.
Purpose of the Study:
- To establish consensus on best practices for imaging cardiac device infections.
- To guide the differentiation between infection and inflammation.
- To provide recommendations for image-guided patient management.
Main Methods:
- Review of current literature on cardiac device infection imaging.
- Evaluation of transthoracic echocardiography, transesophageal echocardiography, cardiac CT, and FDG PET/CT.
- Development of consensus guidelines for patient preparation, image acquisition, processing, interpretation, and reporting.
Main Results:
- FDG PET/CT can detect inflammatory cells early, preceding morphological damage.
- Cardiac CT and FDG PET/CT may offer incremental value in echocardiography-inconclusive cases.
- Standardized reporting is crucial for consistent interpretation.
Conclusions:
- Consensus guidelines are needed to optimize the use of various imaging modalities for cardiac device infections.
- FDG PET/CT holds significant potential for early and accurate diagnosis.
- Standardized protocols will enhance the clinical utility of imaging in managing these complex infections.
Abstract:
The diagnosis of cardiac device infection and, more importantly, accurate localization of the infection site, such as defibrillator pocket, pacemaker lead, along the peripheral driveline or central portion of the left ventricular assist device, prosthetic valve ring abscesses, and perivalvular extensions, remain clinically challenging. Although transthoracic and transesophageal echocardiography are the first-line imaging tests in suspected endocarditis and for assessing hemodynamic complications, recent studies suggest that cardiac computed tomography (CT) or CT angiography and functional imaging with 18F-fluoro-2-deoxyglucose (FDG) positron emission tomography (PET) with CT (FDG PET/CT) may have an incremental role in technically limited or inconclusive cases on echocardiography. One of the key benefits of FDG PET/CT is in its detection of inflammatory cells early in the infection process, before morphological damages ensue. However, there are many unanswered questions in the literature. In this document, we provide consensus on best practices among the various imaging studies, which includes the detection of cardiac device infection, differentiation of infection from inflammation, image-guided patient management, and detailed recommendations on patient preparation, image acquisition, processing, interpretation, and standardized reporting.
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