IMAGES THAT TEACH Diagnosis of peri-valvular abscess by FDG PET/CT imaging in a Bentall aortic root Patrick R. Vargo, MD,a David Min, MD,b Kenneth Varian, MD, PhD,b Vidyasagar Kalahasti, MD,b and Wael A. Jaber, MDb a
Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH b Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH Received May 5, 2015; accepted May 20, 2015 doi:10.1007/s12350-015-0193-5
INTRODUCTION The diagnosis of infection within a prosthetic aortic root can be challenging to make when overt gas and fluid collection is not present on computed tomography (CT). Transesophageal echocardiography (TEE) is an essential tool for the interrogation of the aortic root when there is concern for endocarditis, however, it can be difficult to identify peri-valvular abscess by this modality.1 Fluorodeoxyglucose positron emission tomographycomputed tomography (FDG PET/CT) has been effective in identifying thoracic aortic graft infections and endocarditis by demonstrating inflammation in areas of nonspecific soft tissue and fluid accumulation.2,3 CASE SUMMARY A 58-year-old man with an uncharacterized familial aortic aneurysm and a bioprosthetic aortic valve replacement with composite aortic graft (Bentall Procedure) and remote atrial septal defect repair presented with 2 weeks of fever after an unsuccessfully treated urinary
Electronic supplementary material The online version of this article (doi:10.1007/s12350-015-0193-5) contains supplementary material, which is available to authorized users. Funding No funding was received for this work. Reprint requests: Patrick R. Vargo, MD, Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, J4-133, Cleveland, OH, 44195 [email protected]
tract infection. He was noted to be bradycardic and hypotensive. Resuscitation and empiric antibiotics were initiated, and he was normotensive at the time of imaging. Transesophageal echocardiography identified an echolucent peri-valvular space without flow located at the non-coronary sinus (Figure 1). There was no evidence of vegetations or aortic valve instability. CT angiography similarly demonstrated a non-specific soft tissue change near the non-coronary sinus (Figure 2). Concern for abscess prompted investigation with 18 F-FDG PET/CT, which demonstrated focal uptake surrounding the aortic valve prosthesis consistent with infection and concordant with previous imaging (Figure 3). The patient was not a surgical candidate, and due to persistently negative cultures he was treated medically with broad-spectrum antibiotics. The patient improved clinically, and subsequent TEE imaging at 6 weeks showed resolution of the echolucent peri-valvular space (Figure 4).
J Nucl Cardiol 1071-3581/$34.00 Copyright Ó 2015 American Society of Nuclear Cardiology.
Vargo et al Diagnosis of peri-valvular abscess by FDG PET/CT imaging
Journal of Nuclear CardiologyÒ
Figure 1. Transesophageal echocardiography (TEE) demonstrating fluid collection (white arrow) adjacent to the noncoronary sinus of the bioprosthetic aortic valve; Ao, Aorta; LA, Left Atrium. Figure 2. Computed tomography (CT) angiography of the chest demonstrating soft tissue abnormality (white arrow) adjacent to the non-coronary sinus of a bioprosthetic aortic valve.
Journal of Nuclear CardiologyÒ
Vargo et al Diagnosis of peri-valvular abscess by FDG PET/CT imaging
Figure 3. Positron emission tomography-computed tomography (PET/CT) 60 minutes following the intravenous administration of 5.1 mCi (188.7 MBq) of 18F- fluorodeoxyglucose, which identifies increased uptake adjacent to the prosthetic aortic valve and root (white arrows).
Vargo et al Diagnosis of peri-valvular abscess by FDG PET/CT imaging
Journal of Nuclear CardiologyÒ
Disclosure The authors declare no conflicts of interest.
References
Figure 4. Repeat transesophageal echocardiography (TEE) after 6 weeks of antibiotic therapy showing resolution of the fluid collection noted in previous imaging; Ao, aorta; LA, left atrium.
1. Hill EE, Herijgers P, Claus P, Vanderschueren S, Peetermans WE, Herregods MC. Abscess in infective endocarditis: The value of transesophageal echocardiography and outcome: A 5-year study. Am Heart J 2007;154:923-8. 2. Tokuda Y, Oshima H, Araki Y, Narita Y, Mutsuga M, Kato K, et al Detection of thoracic aortic prosthetic graft infection with 18Ffluorodeoxyglucose positron emission tomography/computed tomography. Eur J Cardiothorac Surg 2013;43:1183-7. 3. Ricciardi A, Sordillo P, Ceccarelli L, Maffongelli G, Calisti G, Di Pietro B, 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;28:219-24.
Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH b Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH Received May 5, 2015; accepted May 20, 2015 doi:10.1007/s12350-015-0193-5
INTRODUCTION The diagnosis of infection within a prosthetic aortic root can be challenging to make when overt gas and fluid collection is not present on computed tomography (CT). Transesophageal echocardiography (TEE) is an essential tool for the interrogation of the aortic root when there is concern for endocarditis, however, it can be difficult to identify peri-valvular abscess by this modality.1 Fluorodeoxyglucose positron emission tomographycomputed tomography (FDG PET/CT) has been effective in identifying thoracic aortic graft infections and endocarditis by demonstrating inflammation in areas of nonspecific soft tissue and fluid accumulation.2,3 CASE SUMMARY A 58-year-old man with an uncharacterized familial aortic aneurysm and a bioprosthetic aortic valve replacement with composite aortic graft (Bentall Procedure) and remote atrial septal defect repair presented with 2 weeks of fever after an unsuccessfully treated urinary
Electronic supplementary material The online version of this article (doi:10.1007/s12350-015-0193-5) contains supplementary material, which is available to authorized users. Funding No funding was received for this work. Reprint requests: Patrick R. Vargo, MD, Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, J4-133, Cleveland, OH, 44195 [email protected]
tract infection. He was noted to be bradycardic and hypotensive. Resuscitation and empiric antibiotics were initiated, and he was normotensive at the time of imaging. Transesophageal echocardiography identified an echolucent peri-valvular space without flow located at the non-coronary sinus (Figure 1). There was no evidence of vegetations or aortic valve instability. CT angiography similarly demonstrated a non-specific soft tissue change near the non-coronary sinus (Figure 2). Concern for abscess prompted investigation with 18 F-FDG PET/CT, which demonstrated focal uptake surrounding the aortic valve prosthesis consistent with infection and concordant with previous imaging (Figure 3). The patient was not a surgical candidate, and due to persistently negative cultures he was treated medically with broad-spectrum antibiotics. The patient improved clinically, and subsequent TEE imaging at 6 weeks showed resolution of the echolucent peri-valvular space (Figure 4).
J Nucl Cardiol 1071-3581/$34.00 Copyright Ó 2015 American Society of Nuclear Cardiology.
Vargo et al Diagnosis of peri-valvular abscess by FDG PET/CT imaging
Journal of Nuclear CardiologyÒ
Figure 1. Transesophageal echocardiography (TEE) demonstrating fluid collection (white arrow) adjacent to the noncoronary sinus of the bioprosthetic aortic valve; Ao, Aorta; LA, Left Atrium. Figure 2. Computed tomography (CT) angiography of the chest demonstrating soft tissue abnormality (white arrow) adjacent to the non-coronary sinus of a bioprosthetic aortic valve.
Journal of Nuclear CardiologyÒ
Vargo et al Diagnosis of peri-valvular abscess by FDG PET/CT imaging
Figure 3. Positron emission tomography-computed tomography (PET/CT) 60 minutes following the intravenous administration of 5.1 mCi (188.7 MBq) of 18F- fluorodeoxyglucose, which identifies increased uptake adjacent to the prosthetic aortic valve and root (white arrows).
Vargo et al Diagnosis of peri-valvular abscess by FDG PET/CT imaging
Journal of Nuclear CardiologyÒ
Disclosure The authors declare no conflicts of interest.
References
Figure 4. Repeat transesophageal echocardiography (TEE) after 6 weeks of antibiotic therapy showing resolution of the fluid collection noted in previous imaging; Ao, aorta; LA, left atrium.
1. Hill EE, Herijgers P, Claus P, Vanderschueren S, Peetermans WE, Herregods MC. Abscess in infective endocarditis: The value of transesophageal echocardiography and outcome: A 5-year study. Am Heart J 2007;154:923-8. 2. Tokuda Y, Oshima H, Araki Y, Narita Y, Mutsuga M, Kato K, et al Detection of thoracic aortic prosthetic graft infection with 18Ffluorodeoxyglucose positron emission tomography/computed tomography. Eur J Cardiothorac Surg 2013;43:1183-7. 3. Ricciardi A, Sordillo P, Ceccarelli L, Maffongelli G, Calisti G, Di Pietro B, 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;28:219-24.
