Surgical decision-making in aortic prosthetic valve endocarditis: the influence of electrocardiogram-gated computed tomography

OBJECTIVES: The aim of this study was to investigate the value of electrocardiogram (ECG)-gated computed tomography (CT) in the surgical decision-making and preoperative evaluation in patients with aortic prosthetic valve endocarditis (PVE). METHODS: Sixty-eight prosthetic valves in 67 patients with aortic PVE were prospectively evaluated with ECG-gated CT and transoesophageal echocardiography (TEE). Imaging findings considered indications for surgery were as follows: (i) abscess/pseudoaneurysm formation; (ii) prosthetic valve dehiscence; (iii) valve destruction with valvular regurgitation; (iv) large vegetations (> 1.5 cm). The coronary arteries were evaluated with ECG-gated CT. Clinical data including surgical reports and mortality data were collected. RESULTS: Fifty-eight of 68 cases had indication for surgery based on imaging findings (ECG-gated CT/TEE). In 8 of these cases (14%), there was indication for surgery based on CT but not on TEE findings (all had perivalvular pseudoaneurysms). In 11 cases (19%), there was indication for surgery based on TEE but not on CT findings [non-drained abscess (n = 5), prosthetic valve dehiscence (n = 4), large vegetation (n = 1), valve destruction (n = 1)]. In 31 of 32 patients with indication for preoperative coronary angiography, ECG-gated CT coronary angiography was diagnostic. In 1 patient, ECG-gated CT coronary angiography was inconclusive and invasive coronary angiography was performed. CONCLUSIONS: In patients with aortic PVE, ECG-gated CT provides additional information over TEE regarding perivalvular extension of infection, which can influence surgical decision-making. Furthermore, ECG-gated CT provides a non-invasive coronary angiogram and can in most cases replace invasive coronary angiography in the preoperative evaluation.