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.

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