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CLINICAL RESEARCH: ECHOCARDIOGRAPHY

The relative roles of transthoracic compared with transesophageal echocardiography in children with suspected infective endocarditis

Tilman Humpl, MD^*, Brian W. McCrindle, MD, FACC^*, and Jeffrey F. Smallhorn, MBBS^*

^* Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada

Manuscript received June 28, 2002; revised manuscript received December 30, 2002, accepted February 25, 2003.

^* Reprint requests and correspondence: Dr. Jeffrey F. Smallhorn, Division of Cardiology, The Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8 Canada.
jsmallho{at}sickkids.ca

OBJECTIVES: The study evaluated the additional benefit of transesophageal echocardiography (TEE) versus transthoracic echocardiography (TTE) in pediatric cases with suspected bacterial endocarditis.

BACKGROUND: In adult patients, TTE has a lower sensitivity and specificity than TEE for the detection of vegetations or aortic root abscess formation. Few data are available about the relative benefits of TEE over TTE in the pediatric age group.

METHODS: Patients were included if they had positive blood cultures for typical microorganisms and had a TTE and TEE within 14 days of each other. The patients had to meet the Duke criteria for a positive diagnosis of bacterial endocarditis. The TTE and TEE data were analyzed using the McNemar test for the significance of change.

RESULTS: Twenty-one patients fulfilled the criteria, at a median age of 9.5 years. Congenital heart disease was present in 13 patients; 4 patients were previously healthy and 4 patients had other medical problems. Nine patients had surgical confirmation of bacterial endocarditis. Fifteen patients had a positive cardiac finding, with 12 vegetations, 2 vegetations plus aortic root abscess, and 1 isolated abscess. There was excellent agreement between TTE and TEE in those cases with positive cardiac findings, with a p = 0.32, kappa 0.89. Using positive TEE cardiac findings as the gold standard, the sensitivity for TTE was 86% for all 15 events and 93% for the detection of a vegetation.

CONCLUSIONS: In pediatric cases, TTE has a high degree of sensitivity for the detection of supportive evidence of endocarditis, and TEE should be reserved for patients with a poor transthoracic window.

Abbreviations and Acronyms   IE   infective endocarditis   TEE   transesophageal echocardiography   TTE   transthoracic echocardiography

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