Sivak Joseph A, Vora Amit N, Navar Ann Marie, Schulte Phillip J, Crowley Anna Lisa, Kisslo Joseph, Corey G Ralph, Liao Lawrence, Wang Andrew, Velazquez Eric J, Samad Zainab
Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina.
Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina.
J Am Soc Echocardiogr. 2016 Apr;29(4):315-22. doi: 10.1016/j.echo.2015.12.009. Epub 2016 Feb 3.
In patients with suspected native valve infective endocarditis, current guidelines recommend initial transthoracic echocardiography (TTE) followed by transesophageal echocardiography (TEE) if clinical suspicion remains. The guidelines do not account for the quality of initial TTE or other findings that may alter the study's diagnostic characteristics. This may lead to unnecessary TEE when initial TTE was sufficient to rule out vegetation.
The objective of this study was to determine if the use of a strict definition of negative results on TTE would improve the performance characteristics of TTE sufficiently to exclude vegetation. A retrospective analysis of patients at a single institution with suspected native valve endocarditis who underwent TTE followed by TEE within 7 days between January 1, 2007, and February 28, 2014, was performed. Negative results on TTE for vegetation were defined by either the standard approach (no evidence of vegetation seen on TTE) or by applying a set of strict negative criteria incorporating other findings on TTE. Using TEE as the gold standard for the presence of vegetation, the diagnostic performance of the two transthoracic approaches was compared.
In total, 790 pairs of TTE and TEE were identified. With the standard approach, 661 of the transthoracic studies had negative findings (no vegetation seen), compared with 104 studies with negative findings using the strict negative approach (meeting all strict negative criteria). The sensitivity and negative predictive value of TTE for detecting vegetation were substantially improved using the strict negative approach (sensitivity, 98% [95% CI, 95%-99%] vs 43% [95% CI, 36%-51%]; negative predictive value, 97% [95% CI, 92%-99%] vs 87% [95% CI, 84%-89%]).
The ability of TTE to exclude vegetation in patients is excellent when strict criteria for negative results are applied. In patients at low to intermediate risk with strict negative results on TTE, follow-up TEE may be unnecessary.
对于疑似自体瓣膜感染性心内膜炎的患者，当前指南推荐首先进行经胸超声心动图（TTE）检查，若临床怀疑仍然存在，则随后进行经食管超声心动图（TEE）检查。这些指南未考虑初始TTE的质量或其他可能改变该检查诊断特征的发现。这可能导致当初始TTE足以排除赘生物时仍进行不必要的TEE检查。
本研究的目的是确定使用对TTE阴性结果的严格定义是否会充分改善TTE的性能特征以排除赘生物。对2007年1月1日至2014年2月28日期间在一家机构内疑似自体瓣膜心内膜炎且在7天内先接受TTE检查随后接受TEE检查的患者进行回顾性分析。TTE检查中赘生物的阴性结果通过标准方法（TTE未发现赘生物证据）或应用一组纳入TTE其他发现的严格阴性标准来定义。以TEE作为赘生物存在的金标准，比较两种经胸检查方法的诊断性能。
总共识别出790对TTE和TEE检查结果。采用标准方法时，661例经胸检查结果为阴性（未发现赘生物），而采用严格阴性方法（符合所有严格阴性标准）时为104例检查结果为阴性。采用严格阴性方法时，TTE检测赘生物的敏感性和阴性预测值显著提高（敏感性，98%[95%CI，95%-99%]对43%[95%CI，36%-51%]；阴性预测值，97%[95%CI，92%-99%]对87%[95%CI，84%-89%]）。
当应用严格的阴性结果标准时，TTE排除患者赘生物的能力极佳。对于TTE检查结果为严格阴性的低至中度风险患者，可能无需进行后续TEE检查。
