Utility of cardiac computed tomography scanning in the diagnosis and pre-operative evaluation of patients with infective endocarditis

  • Jason R. Sims
  • Nandan S. Anavekar
  • Krishnaswamy Chandrasekaran
  • James M. Steckelberg
  • Walter R. Wilson
  • Bernard J. Gersh
  • Larry M. Baddour
  • Daniel C. DeSimone
Original Paper


Transesophageal echocardiography (TEE) is the gold standard imaging study used in the diagnosis of infective endocarditis (IE). Computed tomography angiography (CTA) has undergone rapid advancement as a cardiac imaging technique and has previously shown promise in small non-randomized studies for evaluation of IE. We hypothesized that cardiac CTA would perform similarly to TEE in the detection of endocarditic lesions and that there would be no difference in clinical outcomes whether the coronary arteries were evaluated by CTA or invasive coronary angiography (ICA). 255 adults who underwent surgery for IE at the Mayo Clinic Rochester between January 1, 2006 and June 1, 2014 were identified retrospectively. 251 patients underwent TEE and 34 patients underwent cardiac CTA. TEE had statistically higher detection of vegetations (95.6 vs. 70.0%, p < 0.0001) and leaflet perforations (81.3 vs. 42.9%, p = 0.02) as compared to cardiac CTA. For detection of abscess/pseudoaneurysm TEE had a similar sensitivity to cardiac CTA (90.5 vs. 78.4%, p = 0.21). There was no significant difference in peri-operative outcomes whether coronary arteries were evaluated by CTA or ICA. The greatest advantage of cardiac CT in the setting of IE is its ability to couple the detection of complex cardiac anatomic abnormalities with coronary artery delineation, serving two important components of the diagnostic evaluation, particularly among patients who will require surgical intervention due to IE complications. Cardiac CTA may be considered as an alternate coronary artery imaging modality in IE patients with low to intermediate risk of disease but meet guideline recommendations for coronary artery imaging.


Cardiac CT Infective endocarditis Pre-operative evaluation Valvular heart disease Coronary artery disease 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Supplementary material

10554_2018_1318_MOESM1_ESM.tif (1.1 mb)
Supplementary material 1 (TIF 1112 KB). Timeline of major advances in infective endocarditis with the corresponding study and sample size. IE infective endocarditis, TTE transthoracic echocardiography, TEE transesophageal echocardiography, CT computed tomography, PET positron emission tomography


  1. 1.
    Baddour LM, Wilson WR, Bayer AS, Fowler VG Jr, Tleyjeh IM, Rybak MJ, Barsic B, Lockhart PB, Gewitz MH, Levison ME, Bolger AF, Steckelberg JM, Baltimore RS, Fink AM, O’Gara P, Taubert KA (2015) Infective endocarditis in adults: diagnosis, antimicrobial therapy, and management of complications: a scientific statement for healthcare professionals from the American Heart Association. Circulation 132(15):1435–1486. CrossRefPubMedGoogle Scholar
  2. 2.
    Baddour LM, Wilson WR, Bayer AS, Fowler VG Jr, Bolger AF, Levison ME, Ferrieri P, Gerber MA, Tani LY, Gewitz MH, Tong DC, Steckelberg JM, Baltimore RS, Shulman ST, Burns JC, Falace DA, Newburger JW, Pallasch TJ, Takahashi M, Taubert KA (2005) Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America. Circulation 111(23):e394-434. CrossRefPubMedGoogle Scholar
  3. 3.
    Habib G, Lancellotti P, Antunes MJ, Bongiorni MG, Casalta JP, Del Zotti F, Dulgheru R, El Khoury G, Erba PA, Iung B, Miro JM, Mulder BJ, Plonska-Gosciniak E, Price S, Roos-Hesselink J, Snygg-Martin U, Thuny F, Tornos Mas P, Vilacosta I, Zamorano JL, Erol C, Nihoyannopoulos P, Aboyans V, Agewall S, Athanassopoulos G, Aytekin S, Benzer W, Bueno H, Broekhuizen L, Carerj S, Cosyns B, De Backer J, De Bonis M, Dimopoulos K, Donal E, Drexel H, Flachskampf FA, Hall R, Halvorsen S, Hoen B, Kirchhof P, Lainscak M, Leite-Moreira AF, Lip GY, Mestres CA, Piepoli MF, Punjabi PP, Rapezzi C, Rosenhek R, Siebens K, Tamargo J, Walker DM (2015) 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 36(44):3075–3128. CrossRefPubMedGoogle Scholar
  4. 4.
    Entrikin DW, Gupta P, Kon ND, Carr JJ (2012) Imaging of infective endocarditis with cardiac CT angiography. J Cardiovasc Comput Tomogr 6(6):399–405. CrossRefPubMedGoogle Scholar
  5. 5.
    Sun Z, Ng KH (2010) Multislice CT angiography in cardiac imaging. Part II: clinical applications in coronary artery disease. Singap Med J 51(4):282–289Google Scholar
  6. 6.
    Agatston AS, Janowitz WR, Hildner FJ, Zusmer NR, Viamonte M Jr, Detrano R (1990) Quantification of coronary artery calcium using ultrafast computed tomography. J Am Coll Cardiol 15(4):827–832CrossRefPubMedGoogle Scholar
  7. 7.
    Prendergast BD, Tornos P (2010) Surgery for infective endocarditis: who and when? Circulation 121(9):1141–1152. CrossRefPubMedGoogle Scholar
  8. 8.
    Byrne JG, Rezai K, Sanchez JA, Bernstein RA, Okum E, Leacche M, Balaguer JM, Prabhakaran S, Bridges CR, Higgins RS (2011) Surgical management of endocarditis: the society of thoracic surgeons clinical practice guideline. Ann Thorac Surg 91(6):2012–2019. CrossRefPubMedGoogle Scholar
  9. 9.
    Bashore TM, Balter S, Barac A, Byrne JG, Cavendish JJ, Chambers CE, Hermiller JB Jr, Kinlay S, Landzberg JS, Laskey WK, McKay CR, Miller JM, Moliterno DJ, Moore JW, Oliver-McNeil SM, Popma JJ, Tommaso CL (2012) 2012 American College of Cardiology Foundation/Society for Cardiovascular Angiography and Interventions expert consensus document on cardiac catheterization laboratory standards update: a report of the American College of Cardiology Foundation Task Force on Expert Consensus documents developed in collaboration with the Society of Thoracic Surgeons and Society for Vascular Medicine. J Am Coll Cardiol 59(24):2221–2305. CrossRefPubMedGoogle Scholar
  10. 10.
    Shamsham F, Safi AM, Pomerenko I, Salciccioli L, Feit A, Clark LT, Alam M (2000) Fatal left main coronary artery embolism from aortic valve endocarditis following cardiac catheterization. Catheter Cardiovasc Interv 50(1):74–77CrossRefPubMedGoogle Scholar
  11. 11.
    Budoff MJ, Dowe D, Jollis JG, Gitter M, Sutherland J, Halamert E, Scherer M, Bellinger R, Martin A, Benton R, Delago A, Min JK (2008) Diagnostic performance of 64-multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: results from the prospective multicenter ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography) trial. J Am Coll Cardiol 52(21):1724–1732. CrossRefPubMedGoogle Scholar
  12. 12.
    Abdulla J, Abildstrom SZ, Gotzsche O, Christensen E, Kober L, Torp-Pedersen C (2007) 64-multislice detector computed tomography coronary angiography as potential alternative to conventional coronary angiography: a systematic review and meta-analysis. Eur Heart J 28(24):3042–3050. CrossRefPubMedGoogle Scholar
  13. 13.
    Hamon M, Biondi-Zoccai GG, Malagutti P, Agostoni P, Morello R, Valgimigli M (2006) Diagnostic performance of multislice spiral computed tomography of coronary arteries as compared with conventional invasive coronary angiography: a meta-analysis. J Am Coll Cardiol 48(9):1896–1910. CrossRefPubMedGoogle Scholar
  14. 14.
    Miller JM, Rochitte CE, Dewey M, Arbab-Zadeh A, Niinuma H, Gottlieb I, Paul N, Clouse ME, Shapiro EP, Hoe J, Lardo AC, Bush DE, de Roos A, Cox C, Brinker J, Lima JA (2008) Diagnostic performance of coronary angiography by 64-row CT. N Engl J Med 359(22):2324–2336. CrossRefPubMedGoogle Scholar
  15. 15.
    Nieman K, Cademartiri F, Lemos PA, Raaijmakers R, Pattynama PM, de Feyter PJ (2002) Reliable noninvasive coronary angiography with fast submillimeter multislice spiral computed tomography. Circulation 106(16):2051–2054CrossRefPubMedGoogle Scholar
  16. 16.
    Sun Z, Almutairi AM (2010) Diagnostic accuracy of 64 multislice CT angiography in the assessment of coronary in-stent restenosis: a meta-analysis. Eur J Radiol 73(2):266–273. CrossRefPubMedGoogle Scholar
  17. 17.
    Sun Z, Lin C, Davidson R, Dong C, Liao Y (2008) Diagnostic value of 64-slice CT angiography in coronary artery disease: a systematic review. Eur J Radiol 67(1):78–84. CrossRefPubMedGoogle Scholar
  18. 18.
    Habets J, Tanis W, van Herwerden LA, van den Brink RB, Mali WP, de Mol BA, Chamuleau SA, Budde RP (2014) Cardiac computed tomography angiography results in diagnostic and therapeutic change in prosthetic heart valve endocarditis. Int J Cardiovasc Imaging 30(2):377–387. CrossRefPubMedGoogle Scholar
  19. 19.
    Arbab-Zadeh A, Miller JM, Rochitte CE, Dewey M, Niinuma H, Gottlieb I, Paul N, Clouse ME, Shapiro EP, Hoe J, Lardo AC, Bush DE, de Roos A, Cox C, Brinker J, Lima JA (2012) Diagnostic accuracy of computed tomography coronary angiography according to pre-test probability of coronary artery disease and severity of coronary arterial calcification. The CORE-64 (Coronary Artery Evaluation Using 64-Row Multidetector Computed Tomography Angiography) International Multicenter Study. J Am Coll Cardiol 59(4):379–387. CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Sara L, Rochitte CE, Lemos PA, Niinuma H, Dewey M, Shapiro EP, Gottlieb I, Mansur AP, Nicolau JC, Lardo AC, Azevedo CF, Kalil-Filho R, Vavere AL, Cohn S, Cox C, Brinker J, Miller JM, Lima JA (2014) Accuracy of multidetector computed tomography for detection of coronary artery stenosis in acute coronary syndrome compared with stable coronary disease: a CORE64 multicenter trial substudy. Int J Cardiol 177(2):385–391. CrossRefPubMedGoogle Scholar
  21. 21.
    Meijboom WB, Meijs MF, Schuijf JD, Cramer MJ, Mollet NR, van Mieghem CA, Nieman K, van Werkhoven JM, Pundziute G, Weustink AC, de Vos AM, Pugliese F, Rensing B, Jukema JW, Bax JJ, Prokop M, Doevendans PA, Hunink MG, Krestin GP, de Feyter PJ (2008) Diagnostic accuracy of 64-slice computed tomography coronary angiography: a prospective, multicenter, multivendor study. J Am Coll Cardiol 52(25):2135–2144. CrossRefPubMedGoogle Scholar
  22. 22.
    Malagutti P, Nieman K, Meijboom WB, van Mieghem CA, Pugliese F, Cademartiri F, Mollet NR, Boersma E, de Jaegere PP, de Feyter PJ (2007) Use of 64-slice CT in symptomatic patients after coronary bypass surgery: evaluation of grafts and coronary arteries. Eur Heart J 28(15):1879–1885. CrossRefPubMedGoogle Scholar
  23. 23.
    Cademartiri F, Maffei E, Palumbo A, Seitun S, Martini C, Tedeschi C, La Grutta L, Midiri M, Weustink AC, Mollet NR, Krestin GP (2010) Coronary calcium score and computed tomography coronary angiography in high-risk asymptomatic subjects: assessment of diagnostic accuracy and prevalence of non-obstructive coronary artery disease. Eur Radiol 20(4):846–854. CrossRefPubMedGoogle Scholar
  24. 24.
    Catalan P, Callejo D, Blasco JA (2013) Cost-effectiveness analysis of 64-slice computed tomography vs. cardiac catheterization to rule out coronary artery disease before non-coronary cardiovascular surgery. Eur Heart J Cardiovasc Imaging 14(2):149–157. CrossRefPubMedGoogle Scholar
  25. 25.
    Feuchtner GM, Stolzmann P, Dichtl W, Schertler T, Bonatti J, Scheffel H, Mueller S, Plass A, Mueller L, Bartel T, Wolf F, Alkadhi H (2009) Multislice computed tomography in infective endocarditis: comparison with transesophageal echocardiography and intraoperative findings. J Am Coll Cardiol 53(5):436–444. CrossRefPubMedGoogle Scholar
  26. 26.
    Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP 3rd, Guyton RA, O’Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM, 3rd, Thomas JD (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. J Am Coll Cardiol 63 (22):e57-185. CrossRefPubMedGoogle Scholar
  27. 27.
    Bettencourt N, Rocha J, Carvalho M, Leite D, Toschke AM, Melica B, Santos L, Rodrigues A, Goncalves M, Braga P, Teixeira M, Simoes L, Rajagopalan S, Gama V (2009) Multislice computed tomography in the exclusion of coronary artery disease in patients with presurgical valve disease. Circ Cardiovasc Imaging 2(4):306–313. CrossRefPubMedGoogle Scholar
  28. 28.
    Jakamy R, Barthelemy O, Le Feuvre C, Berman E, Boutekadjirt R, Cluzel P, Metzger JP, Helft G (2012) Accuracy of multislice computed tomography in the preoperative assessment of coronary disease in patients scheduled for heart valve surgery. Arch Cardiovasc Dis 105(8–9):424–431. CrossRefPubMedGoogle Scholar
  29. 29.
    Ciolina F, Sedati P, Zaccagna F, Galea N, Noce V, Miraldi F, Cavarretta E, Francone M, Carbone I (2015) Aortic valve stenosis: non-invasive preoperative evaluation using 64-slice CT angiography. J Cardiovasc Surg 56(5):799–808Google Scholar

Copyright information

© Springer Science+Business Media B.V., part of Springer Nature 2018

Authors and Affiliations

  • Jason R. Sims
    • 1
  • Nandan S. Anavekar
    • 2
    • 3
  • Krishnaswamy Chandrasekaran
    • 2
    • 3
  • James M. Steckelberg
    • 4
  • Walter R. Wilson
    • 4
    • 5
  • Bernard J. Gersh
    • 2
  • Larry M. Baddour
    • 2
    • 4
  • Daniel C. DeSimone
    • 4
  1. 1.Department of Internal MedicineMayo ClinicRochesterUSA
  2. 2.Department of Cardiovascular DiseasesMayo ClinicRochesterUSA
  3. 3.Department of RadiologyMayo ClinicRochesterUSA
  4. 4.Division of Infectious DiseasesMayo ClinicRochesterUSA
  5. 5.Department of Orthopedic SurgeryMayo ClinicRochesterUSA

Personalised recommendations