Skip to main content

Advertisement

SpringerLink
Log in

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

  • Original Article
  • Published:
Pediatric Cardiology Aims and scope Submit manuscript

Abstract

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  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. https://doi.org/10.1161/CIRCULATIONAHA.113.001827

    Article  PubMed  Google Scholar 

  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. https://doi.org/10.1016/j.ijcard.2017.08.009

    Article  PubMed  Google Scholar 

  3. Bragg L, Alvarez A (2014) Endocarditis. Pediatr Rev 35:162–7. https://doi.org/10.1542/pir.35-4-162(quiz 168)

    Article  Google Scholar 

  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. https://doi.org/10.1086/313753

    Article  CAS  PubMed  Google Scholar 

  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. https://doi.org/10.1161/CIR.0000000000000298

    Article  PubMed  Google Scholar 

  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. https://doi.org/10.1007/s00246-010-9709-6

    Article  PubMed  PubMed Central  Google Scholar 

  7. Knirsch W, Nadal D (2011) Infective endocarditis in congenital heart disease. Eur J Pediatr 170:1111–1127. https://doi.org/10.1007/s00431-011-1520-8

    Article  PubMed  Google Scholar 

  8. Marx GR (2006) Infective Endocarditis. In: Keane, John F; Lock, James E; Fyler DC (ed) Nadas’ pediatric cardiology, 2nd Edition. Saunders, Philadelphia, pp 467–476

  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 1299–1312

  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. https://doi.org/10.1016/j.jpeds.2014.06.026

    Article  PubMed  Google Scholar 

  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. https://doi.org/10.1007/s00246-013-0665-9

    Article  PubMed  Google Scholar 

  12. Elder RW, Baltimore RS (2015) The changing epidemiology of pediatric endocarditis. Infect Dis Clin North Am 29:513–524. https://doi.org/10.1016/j.idc.2015.05.004

    Article  PubMed  Google Scholar 

  13. Wang A, Gaca JG, Chu VH (2018) Management considerations in infective endocarditis: a review. JAMA 320:72–83. https://doi.org/10.1001/jama.2018.7596

    Article  PubMed  Google Scholar 

  14. Von Reyn CF, Levy BS, Arbeit RD et al (1981) Infective endocarditis: an analysis based on strict case definitions. Ann Intern Med 94:505–518

    Article  Google Scholar 

  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 96:200–209

    CAS  PubMed  Google Scholar 

  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:e467

    Article  Google Scholar 

  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 93:730–736

    Article  CAS  Google Scholar 

  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. https://doi.org/10.1067/mpd.2003.42

    Article  PubMed  Google Scholar 

  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 89:273–275

    Article  CAS  Google Scholar 

  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. https://doi.org/10.1016/S0002-9149(99)80415-9

    Article  CAS  PubMed  Google Scholar 

  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 153:950–954

    Article  CAS  Google Scholar 

  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 162:1715–1720

    Article  Google Scholar 

  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 25:703–705

    Article  Google Scholar 

  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. https://doi.org/10.1007/s11739-018-1831-0

    Article  PubMed  Google Scholar 

  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. https://doi.org/10.1161/CIR.0000000000000031

    Article  PubMed  Google Scholar 

  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. https://doi.org/10.1016/S0894-7317(03)00685-0

    Article  PubMed  Google Scholar 

  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. https://doi.org/10.1016/j.jacc.2010.11.002

    Article  Google Scholar 

  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. https://doi.org/10.1016/j.jacc.2014.08.003

    Article  PubMed  Google Scholar 

  29. Penk JS, Webb CL, Shulman ST, Anderson EJ (2011) Echocardiography in pediatric infective endocarditis. Pediatr Infect Dis J 30:1109–1111. https://doi.org/10.1097/INF.0b013e31822d320b

    Article  PubMed  Google Scholar 

  30. Tattevin P, Watt G, Revest M et al (2015) Update on blood culture-negative endocarditis. Med Mal Infect 45:1–8. https://doi.org/10.1016/j.medmal.2014.11.003

    Article  CAS  PubMed  Google Scholar 

  31. Hoen B, Duval X (2013) Clinical practice. Infective endocarditis. N Engl J Med 368:1425–1433. https://doi.org/10.1056/NEJMcp1206782

    Article  CAS  PubMed  Google Scholar 

  32. Robinson J (2005) Practical approach to catheter-related bloodstream infections in paediatrics. Paediatr Child Health 10:465–470

    PubMed  PubMed Central  Google Scholar 

Download references

Funding

No external funding was received for this manuscript.

Author information

Authors and Affiliations

  1. Oregon Health & Science University, Portland, OR, USA

    Patrick Kelly, Nancy Hua, Erin J. Madriago, Kathryn W. Holmes, Robin Shaughnessy & Christina Ronai

  2. Division of Cardiology, Department of Pediatrics, Doernbecher Children’s Hospital, 707 SW Gaines St., CDRC-P, Portland, OR, 97239, USA

    Nancy Hua, Erin J. Madriago, Kathryn W. Holmes, Robin Shaughnessy & Christina Ronai

Authors
  1. Patrick Kelly
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Nancy Hua
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Erin J. Madriago
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Kathryn W. Holmes
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Robin Shaughnessy
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Christina Ronai
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Christina Ronai.

Ethics declarations

Conflict of interest

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

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kelly, P., Hua, N., Madriago, E.J. et al. The Utility of Echocardiography in Pediatric Patients with Structurally Normal Hearts and Suspected Endocarditis. Pediatr Cardiol 41, 62–68 (2020). https://doi.org/10.1007/s00246-019-02222-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00246-019-02222-z

Keywords

Search

Navigation