Elsevier

American Heart Journal

Volume 261, July 2023, Pages 21-34
American Heart Journal

Review Articles
Meta‐analysis assessing the sensitivity and specificity of 18F‐FDG PET/CT for the diagnosis of prosthetic valve endocarditis (PVE) using individual patient data (IPD)

https://doi.org/10.1016/j.ahj.2023.03.004Get rights and content

Importance

The use of 18F-FDG PET/CT in diagnostic algorithms for PVE has increased since publication of studies and guidelines advocating its use. The assessment of test accuracy has been limited by small study sizes. We undertook a systematic review using individual patient data (IPD) meta-analysis techniques.

Objective

To estimate the summary sensitivity and specificity of 18F-FDG PET/CT in diagnosing PVE. We also assessed the effect of patient factors on test accuracy as defined by changes in the odds ratios associated with each factor. The effect of the PET/CT study on the final diagnosis was also assessed when compared to the preliminary Duke classification to determine in which patient group 18F-FDG PET/CT had the greatest utility.

Study Selection

Studies were included if PET/CT was performed for suspicion of PVE and IPD of both the PET/CT result and final diagnosis defined by a gold-standard assessment was available. There were 3 possible final diagnoses (“definite PVE,” “possible PVE,” and “rejected PVE”).

Results

Seventeen studies were included with IPD available for 537 patients (from 538 scans). The summary sensitivity and specificity were 85% (95% CI 74.2%–91.8%) and 86.5% (95% CI 75.8%–92.9%) respectively when patients with final diagnosis of “possible PVE” were classified as positive for PVE. When this group was classified as negative for PVE, sensitivity was 87.4% (95% CI 80.4%–92.1%) and specificity was 84.9% (95% CI 71.5%–92.6%). Patients with a known pathogen (especially coagulase negative staphylococcal species), elevated CRP, a biological or aortic valve infection appeared more likely to have an accurate PET/CT diagnosis. Those with a mechanical valve, prior antibiotic treatment or a transcatheter aortic valve replacement valve were less likely to have an accurate test. Time since valve implantation and the presence of surgical adhesive did not appear to affect test accuracy. Of the patients with a preliminary Duke classification of “possible PVE,” 84% received a more conclusive final diagnosis of “definite” or “rejected” PVE after the PET/CT study.

Conclusions and Relevance

18F-FDG PET/CT has high sensitivity and specificity in diagnosing PVE and the diagnostic utility is greatest in patients with a preliminary Duke classification of “possible PVE.” Some patient factors appear to affect test accuracy, though these results should be interpreted with caution given low patient numbers for subgroup analyses.

Section snippets

Methods

This systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis of Individual Participant Data (PRISMA-IPD).13 The initial research protocol was registered with PROSPERO (CRD42020148707).

Results

Seventeen studies were included (Figure 1), their characteristics are described in Table I. IPD was available for 537 patients (from 538 scans). Patient characteristics are summarised in Table II. In 7 of the 17 studies a final diagnosis of “possible PVE” was a potential diagnosis. Across all studies, there were 47 “possible PVE,” 299 “definite PVE,” and 192 “rejected PVE” diagnoses. Table III also outlines the difference between the patients’ preliminary Duke classification and their final

Discussion

In addition to confirming that 18F-FDG PET/CT has a high sensitivity and specificity in diagnosing PVE, this IPD meta-analysis identifies factors which may affect the accuracy of the test. Patients with a known pathogen; elevated CRP; a biological or aortic valve infection appeared more likely to receive an accurate PET result whereas patients with a mechanical valve; prior antibiotic treatment or a TAVR valve appeared less likely to have an accurate test result. Pertinent clinical factors of

Conclusions

18F-FDG PET/CT has a high sensitivity and specificity in diagnosing PVE and the diagnostic utility is greatest in patients with a preliminary Duke classification of “possible PVE” as most of these patients received a more definitive classification of “definite” or “rejected” PVE following the PET study. This study shows this accuracy does not appear to be affected in the early post-operative period or in the presence of surgical adhesive. The diagnostic accuracy may be higher in patients with

Conflict of interest

None reported.

Funding

No extramural funding was used to support this work.

The authors are solely responsible for the design and conduct of this study, all study analyses, the drafting, and editing of the paper and its final contents.

Acknowledgments

We acknowledge the assistance of the following in the interpretation or contribution of data:

Dr Igor Fomin, Dr Raphael Abegão de Camargo, Dr Asbjorn Schøltens, Dr Diana Pursanova and Dr Ulla Hohenthal.

References (40)

  • DR Murdoch et al.

    Clinical presentation, etiology, and outcome of infective endocarditis in the 21st century: the International Collaboration on Endocarditis-Prospective Cohort Study

    Arch Intern Med

    (2009)
  • S Kaur et al.

    Transcatheter aortic valve replacement associated infective endocarditis: a clinical update

    Structural Heart: J Heart Team

    (2020)
  • G Habib et al.

    2015 ESC Guidelines for the management of infective endocarditis: the Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM)

    Eur Heart J

    (2015)
  • GB Pettersson et al.

    Current AATS guidelines on surgical treatment of infective endocarditis

    Ann Cardiothorac Surg

    (2019)
  • DT Durack et al.

    New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke Endocarditis Service

    Am J Med

    (1994)
  • JS Li et al.

    Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis

    Clin Infect Dis

    (2000)
  • M Mahmood et al.

    Meta-analysis of 18F-FDG PET/CT in the diagnosis of infective endocarditis

    J Nucl Cardiol

    (2019)
  • L Saby et al.

    Positron emission tomography/computed tomography for diagnosis of prosthetic valve endocarditis: increased valvular 18F-fluorodeoxyglucose uptake as a novel major criterion

    J Am Coll Cardiol

    (2013)
  • J Yan et al.

    The role of 18F-FDG PET/CT in infectious endocarditis: a systematic review and meta-analysis

    Int J Clin Pharmacol Ther

    (2016)
  • TKM Wang et al.

    Diagnosis of infective endocarditis by subtype using

    Circ Cardiovasc Imaging

    (2020)
  • LE Swart et al.

    Improving the diagnostic performance of 18F-fluorodeoxyglucose positron-emission tomography/computed tomography in prosthetic heart valve endocarditis

    Circulation

    (2018)
  • AM Scholtens et al.

    Confounders in FDG-PET/CT imaging of suspected prosthetic valve endocarditis

    JACC Cardiovasc Imaging

    (2016)
  • LA Stewart et al.

    Preferred reporting items for systematic review and meta-analyses of individual participant data: the PRISMA-IPD statement

    JAMA

    (2015)
  • AS Glas et al.

    The diagnostic odds ratio: a single indicator of test performance

    J Clin Epidemiol

    (2003)
  • L Irwig et al.

    Meta-analytic methods for diagnostic test accuracy

    J Clin Epidemiol

    (1995)
  • H Chu et al.

    Bivariate meta-analysis of sensitivity and specificity with sparse data: a generalized linear mixed model approach

    J Clin Epidemiol

    (2006)
  • RD Riley et al.

    Meta-analysis of diagnostic test studies using individual patient data and aggregate data

    Stat Med

    (2008)
  • A Ricciardi et al.

    18-Fluoro-2-deoxyglucose positron emission tomography-computed tomography: an additional tool in the diagnosis of prosthetic valve endocarditis

    Int J Infect Dis

    (2014)
  • MN Pizzi et al.

    improving the diagnosis of infective endocarditis in prosthetic valves and intracardiac devices with 18F-fluordeoxyglucose positron emission tomography/computed tomography angiography: initial results at an infective endocarditis referral center

    Circulation

    (2015)
  • E Fagman et al.

    18F-FDG PET/CT in the diagnosis of prosthetic valve endocarditis

    Int J Cardiovasc Imaging

    (2016)

    • Cited by (0)

    View full text
    © 2023 Elsevier Inc. All rights reserved.