Beyond echocardiography: whole-body CT's role in redefining IE diagnosis and management

Abstract

Septic embolization, heart failure, perivalvular involvement and uncontrolled infection represent frequent complications of infective endocarditis (IE). All aforementioned complications constitute indications for surgical intervention.

Aims

This study aimed to evaluate usfulness of changes in the diagnostic protocol for patients with left-sided IE, specifically the implementation of routine whole-body computed tomography (CT) scans (brain, chest, abdomen) as the standard of care—in line with the ESC guidelines—and its effect on identifying disease embolic and perivalvular complications and the impact on surgical indications.

Methods

This retrospective study analyzed 366 patients admitted with left-sided IE from 2015 to 2024. The adoption of routine whole-body CT as a new diagnostic standard enabled assessment of the incidence and types of septic embolic events and perivalvular complications, and their influence on surgical decision-making.

Results

Of 366 patients with left-sided IE, 132 (36.1%) underwent routine whole-body CT (brain, chest, abdomen). CT utilization was significantly higher in later years [2021-2024: 60.6% vs 2015-2020: 23.0%, p<0.001]. Septic complications were identified in the spleen (56 patients; 42.4%), brain (28 patients; 21.2%), and other sites (e.g., liver, kidneys, spine; 23 patients; 17.4%). Perivalvular complications -pseudoaneurysms- were detected significantly more often on CT than echocardiography (p<0.01).

Surgical treatment was performed in 268 patients (73.2%). Among all operated patients who had routine whole-body CT [n=94; 35.1%], the primary indication was embolism prevention [45 patients; 47.9% vs. 40; 23.0%; OR 3.07 (95% CI: 1.80-5.26); p<0.001]. In patients without whole-body CT [n=174; 64.9%], heart failure predominated [82; 47.1% vs. 18; 19.1%; OR 0.26 (95% CI: 0.15-0.48); p<0.001].

Conclusions

Routine whole-body CT has substantially improved the detection of embolic complications (especially splenic and cerebral) and perivalvular complications.

Surgical indications have shifted from heart failure towards embolism prevention. These findings underscore the value of routine whole-body CT in optimizing IE treatment and potentially reducing the risk of embolism through early intervention, however, its adoption remains suboptimal.