Journal of Nuclear Cardiology

, Volume 25, Issue 6, pp 2092–2095 | Cite as

Quantification of FDG uptake in patients with a suspicion of prosthetic valve endocarditis: Part of the problem or part of the solution?

  • Fabien HyafilEmail author
  • François Rouzet
  • Dominique Le Guludec

Diagnostic Criteria for FDG-PET in Patients with a Suspicion of PVE

During the past 5 years, FDG-PET imaging has demonstrated its incremental value over echocardiography for the detection of prosthetic valve endocarditis (PVE).1,2 The results of these studies lead to the inclusion of the presence of an abnormal signal in the valvular region on FDG-PET imaging as a major criterion for the diagnosis of PVE in the recently published guidelines of the European Society of Cardiology.3 An important remaining issue for the interpretation of FDG-PET in patients with a suspicion of PVE is the lack of established diagnostic criteria to define what should be considered as an abnormal signal. The quantification of FDG uptake in valves might represent an interesting criterion among others for the analysis of PET images. In this issue of JNC, Scholtens et al.4 describe the range of values that have been identified in valves with FDG-PET in the existing literature. Interestingly, they found the values measured in valves of patients with definite or rejected PVE to be highly variable between centers. This work questions the significance of the intensity of valvular FDG uptake for the diagnostic of PVE.

Standardization of PET Protocols in Patients with PVE

There may be several explanations for this important variability in values measured in the valves. First, PET acquisition protocols differed between centers. Consequently, Scholtens et al.4 suggest to implement PET reconstruction protocols recommended by the European Association of Nuclear Medicine Research Ltd. (EARL) accreditation that have been developed for multi-centric studies in oncology5 for the imaging of patients with a suspicion of PVE. EARL protocols require to reconstruct image with large voxels and high level of smoothing in order to obtain comparable values in centers with different generations of PET systems. These protocols are, however, not appropriate for the imaging of patients with PVE because the focal and often weak FDG signal in valves will tend to be diluted in background signal owing to important partial volume effects on images at low spatial resolution.6 A reasonable alternative would be to agree on dedicated PET protocols for the imaging of patients with a suspicion of PVE that offer a compromise between image quality and the need for standardization of PET acquisitions, in a similar way to what has already been proposed for the imaging of atherosclerosis that present similar constraints.7 Second, valves are subjected to important cardiac and respiratory motion. Signal quantification would certainly benefit from the development of dual cardiac and respiratory gating and motion correction of PET acquisitions. Third, a consensus needs to be reached on the methodology applied for the quantification of the FDG signal in valves. In most clinical studies, two main metrics have been described so far: maximal SUV in the valvular region, and prosthesis to background ratio (PBR), which is usually calculated by dividing the maximal SUV measured on three adjacent slices centered on the valve with the mean SUV of blood measured in the right atrium. The two values included in PBR are similarly affected by variations in the activity of FDG injected to patients, the delay between injection and acquisition and PET acquisition parameters. PBR, as ratio between two values, is therefore less susceptible than SUV to be affected by these approximations and seems therefore the most robust metrics to compare the intensity of FDG uptake in valves between different centers. Forth, high FDG uptake in the myocardium can lead to overestimation of valvular SUV measured in the valvular region because of FDG signal spreading from the myocardium and local increase in image noise. For these reasons, patients with a suspicion of PVE scheduled for PET imaging should be prepared with a high fat, low carb diet before the imaging that allows in most patients for the suppression of FDG uptake in the myocardium.8 Taken together, the implementation of these recommendations will support a more reliable and robust quantification of FDG uptake in valves.

Intrinsic Limitations of Signal Quantification in PVE

One important challenge that cannot be overcome by improving acquisition protocols is that PVE can cause a large variety of valvular or peri-valvular lesions that have different intensities of FDG uptake: the intensity of FDG uptake in a vegetation is lower than in pre-suppurative tissue owing to the difference in the number of activated leucocytes present in each lesion.9 The intensity of FDG uptake in valve can also vary according to the germ involved in PVE and to the duration of antibiotherapy before imaging. Hence, the identification of diagnostic criteria for PVE requires the comparison of a large number of FDG-PET studies to take into account the multiple clinical, biological and imaging characteristics that can influence the aspects and intensity of FDG uptake on PET. In regards to the relative small number of patients with PVE recruited in each center, the identification of relevant diagnostic criteria corresponding to the different clinical presentations of IE would certainly gain from building up large multi-centric registries of patients with PVE imaged with FDG-PET. In this context, the definition of common PET acquisition protocol and metrics in patients imaged for PVE would represent an important first step in order to have reliable and comparable measurements of valvular FDG uptake between centers.

Integrating Clinical, Biology and Imaging for the Diagnostic of PVE

The diagnostic of PVE with FDG-PET can, however, not rely solely on signal quantification in valves. Signal quantification might help to reclassify patients in groups with low, moderate, or high risk of PVE based on ranges of PBR measured in valves. High FDG uptake in the valvular region on PET is very suggestive of active infection (Figure 1), even though intense signal can also be seen in intense inflammatory reaction to foreign material such as biological glue or in case of vasculitis. In contrast, PVE is unlikely in case of mild or absent FDG uptake on PET, but cannot be formally excluded, in particular when PVE is complicated only by a vegetation, or in case of prior antibiotic therapy. The intensity of the signal needs also to be systematically quantified in this group of patients, even in valves presenting no focal FDG uptake on PET, in order to have a better estimation of the range of values that can be expected in patients classified as having a negative study. The interpretation of PET images is the most difficult when FDG uptake is moderate in valves, because this aspect is frequently found in non-infected prosthetic valves in relation to chronic immune reactions and is hard to distinguish from active infection.7 In this situation, additional criteria need to be taken into account such as the pattern of FDG uptake, the persistence of FDG signal on non-attenuation corrected images, the localization of the signal in relation to cardiac structures, and to morphological aspects observed on echocardiography or cardiac CTA.10,11 In particular, the presence of focal or heterogeneous FDG signal extending outside the prosthetic contours is suggestive of infection. If the diagnostic of PVE remains uncertain, radiolabeled leukocyte scintigraphy can be helpful to discriminate between infective and inflammatory processes in valves, as this imaging technique is highly specific for infection.2,12 Nevertheless, the diagnostic of PVE cannot be based only on FDG-PET images and should integrate clinical and biological information, as well as the results of morphological imaging such as echocardiography and CTA.
Figure 1

Representative examples of different intensities of FDG uptake in valves measured in patients imaged with PET for a suspicion of PVE. FDG uptake in the valvular region is intense (SUV max. = 6.8; PBR = 3.8) and heterogeneous in a patient with confirmed PVE (left column), moderate (SUV max; = 3.5; PBR = 1.8) and heterogeneous in a patient with confirmed PVE (center column), and mild (SUV max. = 3.1; PBR = 1.5) and diffuse in a patient with rejected PVE (right column). The same scales were used for all PET images


In summary, efforts should be directed towards defining common PET acquisition protocols and metrics for the evaluation of patients with a suspicion of PVE. This should facilitate the comparison of measurements originating from different imaging centers and support the implementation of multi-centric registries in this field. The grading of FDG uptake in valves as intense, moderate, mild or absent might be a more appropriate methodology for the analysis of PET images than a simple classification as positive or negative. The set-up of multi-centric registries would help for the identification of the most relevant thresholds corresponding to each level of valvular FDG uptake and relate these different levels to the probability of PVE in patients. In a similar way to what already exists for the analysis of echocardiography in the Duke classification, the precise quantification of valvular FDG uptake could be the groundwork for the definition of major and minor criteria of PVE using PET in combination with the analysis of the pattern and location of FDG uptake in valvular regions.



F. Hyafil, F. Rouzet and D. Le Guludec have nothing to disclose.


  1. 1.
    Saby L, Laas O, Habib G, Cammilleri S, Mancini J, Tessonnier L, 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;61(23):2374–82.CrossRefGoogle Scholar
  2. 2.
    Rouzet F, Chequer R, Benali K, Lepage L, Ghodbane W, Duval X, et al. Respective performance of 18F-FDG PET and radiolabeled leukocyte scintigraphy for the diagnosis of prosthetic valve endocarditis. J Nucl Med. 2014;55(12):1980–5.CrossRefGoogle Scholar
  3. 3.
    Authors/Task Force M, Habib G, Lancellotti P, Antunes MJ, Bongiorni MG, Casalta JP, 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;36:3075–128.CrossRefGoogle Scholar
  4. 4.
    Scholtens AM, Swart LE, Kolste HJT, Budde RPJ, Lam MGEH, Verberne HJ. Standardized uptake values in FDG PET/CT for prosthetic heart valve endocarditis: a call for standardization. J Nucl Cardiol. 2017. doi: 10.1007/s12350-017-0932-x.Google Scholar
  5. 5.
    Boellaard R, Delgado-Bolton R, Oyen WJ, Giammarile F, Tatsch K, Eschner W, et al. FDG PET/CT: EANM procedure guidelines for tumour imaging: version 2.0. Eur J Nucl Med Mol Imaging. 2015;42(2):328–54.CrossRefGoogle Scholar
  6. 6.
    Huet P, Burg S, Le Guludec D, Hyafil F, Buvat I. Variability and uncertainty of 18F-FDG PET imaging protocols for assessing inflammation in atherosclerosis: suggestions for improvement. J Nucl Med. 2015;56(4):552–9.CrossRefGoogle Scholar
  7. 7.
    Mathieu C, Mikail N, Benali K, Iung B, Duval X, Nataf P, et al. Characterization of 18F-Fluorodeoxyglucose uptake pattern in noninfected prosthetic heart valves. Circ Cardiovasc Imaging. 2017;10(3):e005585.CrossRefGoogle Scholar
  8. 8.
    Osborne MT, Hulten EA, Murthy VL, Skali H, Taqueti VR, Dorbala S, et al. Patient preparation for cardiac fluorine-18 fluorodeoxyglucose positron emission tomography imaging of inflammation. J Nucl Cardiol. 2017;24(1):86–99.CrossRefGoogle Scholar
  9. 9.
    Salomaki SP, Saraste A, Kemppainen J, Bax JJ, Knuuti J, Nuutila P, et al. 18F-FDG positron emission tomography/computed tomography in infective endocarditis. J Nucl Cardiol. 2017;24(1):195–206.CrossRefGoogle Scholar
  10. 10.
    Hyafil F, Rouzet F, Le Guludec D. Nuclear imaging for patients with a suspicion of infective endocarditis: be part of the team! J Nucl Cardiol. 2015;24:207–11.CrossRefGoogle Scholar
  11. 11.
    Pizzi MN, Roque A, Fernandez-Hidalgo N, Cuellar-Calabria H, Ferreira-Gonzalez I, Gonzalez-Alujas MT, 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;132(12):1113–26.CrossRefGoogle Scholar
  12. 12.
    Hyafil F, Rouzet F, Lepage L, Benali K, Raffoul R, Duval X, et al. Role of radiolabelled leucocyte scintigraphy in patients with a suspicion of prosthetic valve endocarditis and inconclusive echocardiography. Eur Heart J Cardiovasc Imaging. 2013;14(6):586–94.CrossRefGoogle Scholar

Copyright information

© American Society of Nuclear Cardiology 2017

Authors and Affiliations

  • Fabien Hyafil
    • 1
    • 2
    Email author
  • François Rouzet
    • 1
    • 2
  • Dominique Le Guludec
    • 1
    • 2
  1. 1.Department of Nuclear MedicineCentre Hospitalier Universitaire Bichat, Assistance Publique – Hôpitaux de ParisParisFrance
  2. 2.Département Hospitalo-Universitaire FIRE, Inserm 1148Université Paris DiderotParisFrance

Personalised recommendations