Pretet Valentin, Blondet Cyrille, Ruch Yvon, Martinez Matias, El Ghannudi Soraya, Morel Olivier, Hansmann Yves, Schindler Thomas H, Imperiale Alessio
Nuclear Medicine and Molecular Imaging, ICANS, University Hospitals of Strasbourg, rue Albert Calmette, 67093 Strasbourg, France.
Faculty of Medicine, FMTS, University of Strasbourg, 67000 Strasbourg, France.
Diagnostics (Basel). 2021 Apr 18;11(4):720. doi: 10.3390/diagnostics11040720.
According to European Society of Cardiology guidelines (ESC2015) for infective endocarditis (IE) management, modified Duke criteria (mDC) are implemented with a degree of clinical suspicion degree, leading to grades such as "possible" or "rejected" IE despite a persisting high level of clinical suspicion. Herein, we evaluate the F-FDG PET/CT diagnostic and therapeutic impact in IE suspicion, with emphasis on possible/rejected IE with a high clinical suspicion. Excluding cases of definite IE diagnosis, 53 patients who underwent F-FDG PET/CT for IE suspicion were selected and afterwards classified according to both mDC (possible IE/Duke 1, rejected IE/Duke 0) and clinical suspicion degree (high and low IE suspicion). The final status regarding IE diagnosis (gold standard) was based on the multidisciplinary decision of the Endocarditis Team, including the 'imaging specialist'. PET/CT images of the cardiac area were qualitatively interpreted and the intensity of each focus of extra-physiologic F-FDG uptake was evaluated by a maximum standardized uptake value (SUVmax) measurement. Extra-cardiac F-FDG PET/CT pathological findings were considered to be a possible embolic event, a possible source of IE, or even a concomitant infection. Based on the Endocarditis Team consensus, final diagnosis of IE was retained in 19 (36%) patients and excluded in 34 (64%). With a sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and global accuracy of 79%, 100%, 100%, 89%, and 92%, respectively, PET/CT performed significantly better than mDC ( 0.003), clinical suspicion degree ( = 0.001), and a combination of both ( = 0.001) for IE diagnosis. In 41 patients with possible/rejected IE but high clinical suspicion, sensitivity, specificity, PPV, NPV, and global accuracies were 78%, 100%, 100%, 85%, and 90%, respectively. Moreover, PET/CT contributed to patient management in 24 out of 53 (45%) cases. F-FDG PET/CT represents a valuable diagnostic tool that could be proposed for challenging IE cases with significant differences between mDC and clinical suspicion degree. F-FDG PET/CT allows a binary diagnosis (definite or rejected IE) by removing uncertain diagnostic situations, thus improving patient therapeutic management.
根据欧洲心脏病学会（ESC2015）关于感染性心内膜炎（IE）管理的指南，改良的杜克标准（mDC）根据临床怀疑程度实施，导致出现“可能”或“排除”IE等分级，尽管临床怀疑程度一直很高。在此，我们评估了F-FDG PET/CT对IE疑似病例的诊断和治疗影响，重点关注临床高度怀疑的可能/排除IE病例。排除明确诊断为IE的病例，选择53例因疑似IE接受F-FDG PET/CT检查的患者，然后根据mDC（可能IE/杜克1级，排除IE/杜克0级）和临床怀疑程度（高和低IE怀疑）进行分类。IE诊断的最终状态（金标准）基于心内膜炎团队的多学科决策，包括“影像专家”。对心脏区域的PET/CT图像进行定性解读，并通过最大标准化摄取值（SUVmax）测量评估每个生理性外F-FDG摄取灶的强度。心脏外F-FDG PET/CT的病理结果被认为是可能的栓塞事件、可能的IE来源，甚至是合并感染。根据心内膜炎团队的共识，19例（36%）患者最终诊断为IE，34例（64%）被排除。PET/CT诊断IE的敏感性、特异性、阳性预测值（PPV）、阴性预测值（NPV）和总体准确性分别为79%、100%、100%、89%和92%，显著优于mDC（P = 0.003）、临床怀疑程度（P = 0.001）以及两者的组合（P = 0.001）。在41例可能/排除IE但临床高度怀疑的患者中，敏感性、特异性、PPV、NPV和总体准确性分别为78%、100%、100%、85%和90%。此外，PET/CT在53例（45%）病例中对患者管理有帮助。F-FDG PET/CT是一种有价值的诊断工具，可用于mDC与临床怀疑程度存在显著差异的具有挑战性的IE病例。F-FDG PET/CT通过消除不确定的诊断情况实现二元诊断（明确或排除IE），从而改善患者的治疗管理。
