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Year : 2015  |  Volume : 5  |  Issue : 2  |  Page : 130-131

Comparison between transthoracic and transesophageal echocardiogram in the diagnosis of endocarditis: A retrospective analysis

1 Clinical Assistant Professor of Medicine, University of Pittsburgh Medical Center East, Mosside Boulevard, Monroeville, Pennsylvania, USA
2 Clinical Assistant Professor Chief of Infectious Disease, University of Pittsburgh Medical Center Mercy, Locust Street, Pittsburgh, USA

Date of Web Publication9-Jun-2015

Correspondence Address:
Abhishek Biswas
UPMC East, 2775 Mosside Boulevard, Monroeville 15146, Pennsylvania
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2229-5151.158429

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How to cite this article:
Biswas A, Yassin MH. Comparison between transthoracic and transesophageal echocardiogram in the diagnosis of endocarditis: A retrospective analysis. Int J Crit Illn Inj Sci 2015;5:130-1

How to cite this URL:
Biswas A, Yassin MH. Comparison between transthoracic and transesophageal echocardiogram in the diagnosis of endocarditis: A retrospective analysis. Int J Crit Illn Inj Sci [serial online] 2015 [cited 2023 Jan 27];5:130-1. Available from: https://www.ijciis.org/text.asp?2015/5/2/130/158429

Dear Editor,

Echocardiogram forms an integral part of the Duke's criteria and is central to the diagnosis of infective endocarditis (IE). [1] Transthoracic echocardiogram (TTE) has been found to have a lower sensitivity for detection of vegetations (40-60%) [2] as compared to transesophageal echocardiogram (TEE) (94-100%). [3] Yet, TTE is routinely ordered in cases of suspected endocarditis. The American Heart Association (AHA) guidelines recommend TEE as the initial test to rule out endocarditis in high-risk individuals: Patients in which the window for a TTE would be obscured (for example, obese patients), patients with prosthetic valves, patients with pre-existing valvular abnormalities, congenital heart diseases, previous IE, new murmur, heart failure, other stigmata of IE, patients with bacteremia from organisms known to be a cause of endocarditis and patients for which clinicians have a high suspicion of endocarditis. [4]

We performed a retrospective quality improvement study to evaluate any incremental benefit from ordering TTE in high-risk patients with suspected infective endocarditis (IE). The study also looked into the cost analysis of ordering TTE prior to TEE.

The study period was from May 2009 to June 2011. Using standardized billing codes, patients were selected based on the following criteria: Final diagnosis of IE, underwent both TTE and TEE and had presence of vegetations on TEE.

We included 27 high-risk patients who fulfilled the inclusion criteria. We found that TTE detected evidence of vegetations in only 29.6% of the patients. Sensitivity was especially low for detection of vegetation on mitral and tricuspid valves [Table 1].
Table 1: Summary of cases with vegetation on TEE and TTE

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This study demonstrated the limitations of TTE in detection of endocarditis as represented by valvular vegetation, valvular flow abnormalities and ring abscess. With a sensitivity of 29%, TTE would seem to be a poor choice for the initial evaluation of IE. Given that TTE is especially inferior to TEE in detecting vegetation in the mitral (11%) and tricuspid (16.7%) valves. In our study, all patients with tricuspid endocarditis had a history of IV drug use. Therefore, in patients with a history IV drug use, performing TEE as an initial diagnostic test would be a reasonable option. Also, it is known that patients with pre-existing mitral valve disease are susceptible to mitral valve endocarditis, so they might also be considered for TEE as an initial diagnostic tool. Ring abscess was seen on 2 TEEs (one aortic valve and one mitral valve) within our sample population, and TTE was not able to identify either of these.

We also looked at the sensitivity of TTE in diagnosing regurgitant lesions. The sensitivity of TTE was 78% [Table 2]. We used TEE as the gold standard test, and compared TTE to this.
Table 2: Cases with valvular flow abnormalities on TEE and TTE

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From a financial standpoint, ordering TEE initially has the potential to curb significant health care spending while sacrificing little in terms of diagnostics. National Medicare reimbursement rates for TTE and TTE are $367 and $513, respectively. In this study of 27 subjects for example, more than $9,000 could have been saved if TEE had been done as the initial diagnostic test.

   Conclusion Top

TTE does not add any beneficial information and is not cost-effective when applied to high-risk patients.

   References Top

Baddour LM, Wilson WR, Bayer AS, Fowler VG, Bolger AF, Levison ME, et al. 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 2005; 111: e394-434.  Back to cited text no. 1
Shively BK, Gurule FT, Roldan CA, Leggett JH, Schiller NB. Diagnostic value of transesophageal compared with transthoracic echocardiography in infective endocarditis. J Am Coll Cardiol 1991; 18:391-7.  Back to cited text no. 2
Erbel R, Rohmann S, Drexler M, Mohr-Kahaly S, Gerharz C, Iversen S, et al. Improved diagnostic value of echocardiography in patients with infective endocarditis by transoesophageal approach. A prospective study. Eur Heart J 1988;9:43-53.  Back to cited text no. 3
Roe MT, Abramson MA, Li J, Heinle SK, Kisslo J, Corey GR, et al. Clinical information determines the impact of transesophageal echocardiography on the diagnosis of infective endocarditis by the duke criteria. Am Heart J 2000;139: 945-51.  Back to cited text no. 4


  [Table 1], [Table 2]

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