Q: 52 year old male with End Stage Renal Disease is admitted to ICU with fever, hypotension and probable AV graft infection. Infectious Disease (ID) service strongly suspect Infective Endocarditis (IE) but Transesophageal Echocardiography (TEE) failed to provide and definite answer of vegetation. What should be the next step to confirm or rule out Infective Endocarditis(IE)?


Answer: Cardiac CT

If TEE fails to provide definite evidence of IE, the next step is to perform cardiac CT. It is very sensitive, similar in accuracy to detect abscess and pseudoaneurysm, and probably superior to TEE for evaluation of paravalvular extension of infection. It also has an advantage of evaluating the coronary arteries at the same time. From logistic perspective, CT of other parts of the body can be performed at the same time if infective emboli is suspected like to brain or torso.


References:

1. Bruun NE, Habib G, Thuny F, Sogaard P. Cardiac imaging in infectious endocarditis. Eur Heart J 2014; 35:624.

2. Feuchtner GM, Stolzmann P, Dichtl W, et al. Multislice computed tomography in infective endocarditis: comparison with transesophageal echocardiography and intraoperative findings. J Am Coll Cardiol 2009; 53:436.