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J Am Soc Echocardiogr. 2017 Jul;30(7):639-646.e8. doi: 10.1016/j.echo.2017.03.007. Epub 2017 May 5.

Diagnostic Accuracy of Transthoracic Echocardiography for Infective Endocarditis Findings Using Transesophageal Echocardiography as the Reference Standard: A Meta-Analysis.

Author information

1
Department of Medicine, Queen's University, Kingston, Ontario, Canada.
2
Sinai Health System, Toronto, Ontario, Canada.
3
Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
4
Sinai Health System, Toronto, Ontario, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada.
5
Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada.
6
Department of Medicine, University of Toronto, Toronto, Ontario, Canada; University Health Network, Toronto, Ontario, Canada.
7
Sinai Health System, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; University Health Network, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
8
Sinai Health System, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; University Health Network, Toronto, Ontario, Canada. Electronic address: andrew.morris@sinaihealthsystem.ca.

Abstract

BACKGROUND:

Echocardiography is important for the diagnosis of infective endocarditis (IE), for which transesophageal echocardiography (TEE) is superior to transthoracic echocardiography (TTE).

METHODS:

A systematic review and meta-analysis of observational studies was performed with the objective of evaluating diagnostic properties of TTE, with transesophageal findings of IE as the reference standard in patients with suspected IE.

RESULTS:

The literature search yielded 377 unique articles, of which 16 met the inclusion criteria. The 16 studies included 2,807 patients, of whom 793 (28%) had vegetations on TEE. For detecting vegetations, harmonic TTE had sensitivity of 61% (95% CI, 45%-75%) and specificity of 94% (95% CI, 85%-98%) with a negative likelihood ratio (NLR) of 0.42 (95% CI, 0.26-0.61). NLR for harmonic TTE can be improved by including only patients without prosthetic valves (NLR = 0.36; 95% CI, 0.22-0.55) or by having strict criteria for conclusively negative results on TTE (NLR = 0.17; 95% CI, 0.10-0.28). In the setting of patients without prosthetic valves, harmonic TTE had likelihood ratios of 0.14 (95% CI, 0.09-0.23) for a conclusively negative result, 0.66 (95% CI, 0.53-0.81) for an indeterminate result, and 14.60 (95% CI, 3.37-70.40) for a positive result.

CONCLUSIONS:

Modern harmonic TTE still has the potential to miss many vegetations detected on TEE. When limited to patients without prosthetic valves, a conclusively negative TTE under optimal view greatly decreases likelihood of IE. All other transthoracic results are not useful for ruling out IE, and subsequent TEE is almost always required.

KEYWORDS:

Diagnostic accuracy; Echocardiography; Infective endocarditis; Meta-analysis

PMID:
28483353
DOI:
10.1016/j.echo.2017.03.007
[Indexed for MEDLINE]

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