The Utility of Echocardiography in Pediatric Patients with Structurally Normal Hearts and Suspected Endocarditis

  • Patrick Kelly
  • Nancy Hua
  • Erin J. Madriago
  • Kathryn W. Holmes
  • Robin Shaughnessy
  • Christina RonaiEmail author
Original Article


The objective of this study was to evaluate the utility of transthoracic echocardiography (TTE) in children with structurally normal hearts suspected of having infective endocarditis (IE). We hypothesized that the diagnostic yield of TTE is minimal in low-risk patients with normal hearts. We performed a retrospective chart review of TTEs performed for concern for endocarditis at a pediatric tertiary care referral center in Portland, Oregon. Three hundred patients met inclusion criteria (< 21 years old, completed TTE for IE from 2005 to 2015, no history of congenital heart disease or endocarditis). We recorded findings that met the modified Duke criteria (MDC) including fever, positive blood culture, and vascular/immunologic findings; presence of a central line; whether or not patients were diagnosed with IE clinically; and if any changes to antibiotic regimens were made based on TTE. Ten patients (3%) had echocardiograms consistent with IE. When compared to the clinical diagnosis of IE, the positive predictive value (PPV) of one positive blood culture without other major/minor MDC was 0. Similarly, the PPV of two positive blood cultures without other major/minor criteria was 0.071. Patients should be evaluated using the MDC to assess the clinical probability of IE prior to performing a TTE. Patients with a low probability for IE should not undergo TTE as it has a low diagnostic yield and patients are unlikely to be diagnosed with disease.


Endocarditis Echocardiography Modified Duke criteria Screening 



No external funding was received for this manuscript.

Compliance with Ethical Standards

Conflict of interest

The authors have no potential conflicts of interest relevant to this article to disclose.


  1. 1.
    Rushani D, Kaufman JS, Ionescu-Ittu R et al (2013) Infective endocarditis in children with congenital heart disease: cumulative incidence and predictors. Circulation 128:1412–1419. CrossRefPubMedGoogle Scholar
  2. 2.
    Sun L-C, Lai C-C, Wang C-Y et al (2017) Risk factors for infective endocarditis in children with congenital heart diseases - A nationwide population-based case control study. Int J Cardiol 248:126–130. CrossRefPubMedGoogle Scholar
  3. 3.
    Bragg L, Alvarez A (2014) Endocarditis. Pediatr Rev 35:162–7. (quiz 168)
  4. 4.
    Li JS, Sexton DJ, Mick N et al (2000) Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis 30:633–638. CrossRefPubMedGoogle Scholar
  5. 5.
    Baltimore RS, Gewitz M, Baddour LM et al (2015) Infective Endocarditis in Childhood: 2015 Update: A Scientific Statement From the American Heart Association. Circulation 132:1487–1515. CrossRefPubMedGoogle Scholar
  6. 6.
    Rosenthal LB, Feja KN, Levasseur SM et al (2010) The changing epidemiology of pediatric endocarditis at a children’s hospital over seven decades. Pediatr Cardiol 31:813–820. CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Knirsch W, Nadal D (2011) Infective endocarditis in congenital heart disease. Eur J Pediatr 170:1111–1127. CrossRefPubMedGoogle Scholar
  8. 8.
    Marx GR (2006) Infective Endocarditis. In: Keane, John F; Lock, James E; Fyler DC (ed) Nadas’ pediatric cardiology, 2nd Edition. Saunders, Philadelphia, pp 467–476Google Scholar
  9. 9.
    Taubert KA GM (2008) Infective endocarditis. In: Moss and Adam’s Heart Disease in infants, children, and adolescents: including the fetus and young adults, vol 2., 7th edn. Lippincott Williams and Wilkins, Philadelphia, pp 1299–1312Google Scholar
  10. 10.
    Ware AL, Tani LY, Weng H-Y et al (2014) Resource utilization and outcomes of infective endocarditis in children. J Pediatr 165:807–12.e1. CrossRefPubMedGoogle Scholar
  11. 11.
    Marom D, Ashkenazi S, Samra Z, Birk E (2013) Infective endocarditis in previously healthy children with structurally normal hearts. Pediatr Cardiol 34:1415–1421. CrossRefPubMedGoogle Scholar
  12. 12.
    Elder RW, Baltimore RS (2015) The changing epidemiology of pediatric endocarditis. Infect Dis Clin North Am 29:513–524. CrossRefPubMedGoogle Scholar
  13. 13.
    Wang A, Gaca JG, Chu VH (2018) Management considerations in infective endocarditis: a review. JAMA 320:72–83. CrossRefPubMedGoogle Scholar
  14. 14.
    Von Reyn CF, Levy BS, Arbeit RD et al (1981) Infective endocarditis: an analysis based on strict case definitions. Ann Intern Med 94:505–518CrossRefGoogle Scholar
  15. 15.
    Durack DT, Lukes AS, Bright DK (1994) New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke Endocarditis Service. Am J Med 96:200–209PubMedGoogle Scholar
  16. 16.
    Tissières P, Gervaix A, Beghetti M, Jaeggi ET (2003) Value and limitations of the von Reyn, Duke, and modified Duke criteria for the diagnosis of infective endocarditis in children. Pediatrics 112:e467CrossRefGoogle Scholar
  17. 17.
    Lindner JR, Case RA, Dent JM et al (1996) Diagnostic value of echocardiography in suspected endocarditis. An evaluation based on the pretest probability of disease. Circulation 93:730–736CrossRefGoogle Scholar
  18. 18.
    Michelfelder EC, Ochsner JE, Khoury P, Kimball TR (2003) Does assessment of pretest probability of disease improve the utility of echocardiography in suspected endocarditis in children? J Pediatr 142:263–267. CrossRefPubMedGoogle Scholar
  19. 19.
    Greaves K, Mou D, Patel A, Celermajer DS (2003) Clinical criteria and the appropriate use of transthoracic echocardiography for the exclusion of infective endocarditis. Heart 89:273–275CrossRefGoogle Scholar
  20. 20.
    Sable CA, Rome JJ, Martin GR et al (1995) Indications for echocardiography in the diagnosis of infective endocarditis in children. Am J Cardiol 75:801–804. CrossRefPubMedGoogle Scholar
  21. 21.
    Aly AM, Simpson PM, Humes RA (1999) The role of transthoracic echocardiography in the diagnosis of infective endocarditis in children. Arch Pediatr Adolesc Med 153:950–954CrossRefGoogle Scholar
  22. 22.
    Kuruppu JC, Corretti M, Mackowiak P, Roghmann M-C (2002) Overuse of transthoracic echocardiography in the diagnosis of native valve endocarditis. Arch Intern Med 162:1715–1720CrossRefGoogle Scholar
  23. 23.
    Liu Y-W, Tsai W-C, Hsu C-H et al (2009) Judicious use of transthoracic echocardiography in infective endocarditis screening. Can J Cardiol 25:703–705CrossRefGoogle Scholar
  24. 24.
    Bonzi M, Cernuschi G, Solbiati M et al (2018) Diagnostic accuracy of transthoracic echocardiography to identify native valve infective endocarditis: a systematic review and meta-analysis. Intern Emerg Med 13:937–946. CrossRefPubMedGoogle Scholar
  25. 25.
    Nishimura RA, Otto CM, Bonow RO et al (2014) 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 129:e521–643. CrossRefGoogle Scholar
  26. 26.
    Cheitlin MD, Armstrong WF, Aurigemma GP et al (2003) ACC/AHA/ASE 2003 Guideline update for the clinical application of echocardiography: summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to Update the 1997 Guid. J Am Soc Echocardiogr 16:1091–1110. CrossRefPubMedGoogle Scholar
  27. 27.
    American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, et al (2011) ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography. A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Associat. J Am Coll Cardiol 57:1126–66.
  28. 28.
    Campbell RM, Douglas PS, Eidem BW et al (2014) ACC/AAP/AHA/ASE/HRS/SCAI/SCCT/SCMR/SOPE 2014 appropriate Use criteria for initial transthoracic echocardiography in outpatient pediatric cardiology. J Am Coll Cardiol 64:2039–2060. CrossRefPubMedGoogle Scholar
  29. 29.
    Penk JS, Webb CL, Shulman ST, Anderson EJ (2011) Echocardiography in pediatric infective endocarditis. Pediatr Infect Dis J 30:1109–1111. CrossRefPubMedGoogle Scholar
  30. 30.
    Tattevin P, Watt G, Revest M et al (2015) Update on blood culture-negative endocarditis. Med Mal Infect 45:1–8. CrossRefPubMedGoogle Scholar
  31. 31.
    Hoen B, Duval X (2013) Clinical practice. Infective endocarditis. N Engl J Med 368:1425–1433. CrossRefPubMedGoogle Scholar
  32. 32.
    Robinson J (2005) Practical approach to catheter-related bloodstream infections in paediatrics. Paediatr Child Health 10:465–470PubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Oregon Health & Science UniversityPortlandUSA
  2. 2.Division of Cardiology, Department of PediatricsDoernbecher Children’s HospitalPortlandUSA

Personalised recommendations