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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 28  |  Issue : 2  |  Page : 124-126

Three-dimensional transesophageal echocardiographic diagnosis of catheter endocarditis hidden in intracaval stent


1 Department of Emergency and Organ Transplantation, Institute of Cardiovascular Disease, University Hospital Policlinico, Bari, Italy
2 Department of Hospital, Cardiology Unit, Hospital Policlinico, Bari, Italy

Date of Web Publication16-May-2018

Correspondence Address:
Paolo Colonna
Hospital Policlinico, Piazza G. Cesare, Bari 70124
Italy
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcecho.jcecho_12_18

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  Abstract 


In recent years, with an increasing number of central venous access procedures and cardiac implantable electronic device implantation, the incidence of infective endocarditis (IE) has become more prevalent. Two-dimensional transthoracic echocardiography (2D-TTE) and transesophageal echocardiography (TEE) are a key part of the evaluation of IE, but advances in three-dimensional echocardiography have enabled a better spatial resolution and visualization of cardiac structures, allowing the identification of any valvular vegetations, abscesses, or nodules. Herein, we report the usefulness of 3D-TEE in a difficult diagnosis of hemodialysis catheter endocarditis hidden in intracaval stent.

Keywords: Cardiac implantable electronic device, hemodialysis catheter endocarditis, infective endocarditis, lead-dependent infective endocarditis, three-dimensional transesophageal echocardiography


How to cite this article:
Musci RL, Girasoli C, Fumarola F, D'Agostino C, Colonna P. Three-dimensional transesophageal echocardiographic diagnosis of catheter endocarditis hidden in intracaval stent. J Cardiovasc Echography 2018;28:124-6

How to cite this URL:
Musci RL, Girasoli C, Fumarola F, D'Agostino C, Colonna P. Three-dimensional transesophageal echocardiographic diagnosis of catheter endocarditis hidden in intracaval stent. J Cardiovasc Echography [serial online] 2018 [cited 2021 Oct 26];28:124-6. Available from: https://www.jcecho.org/text.asp?2018/28/2/124/232556




  Introduction Top


In recent years, the increased rates of cardiac implantable electronic device (CIED) implantation and central venous access procedures have set the stage for higher rates of infection and the increasing frequency of infective endocarditis (IE).

Two-dimensional transthoracic echocardiography (2D-TTE) and transesophageal echocardiography (TEE) are a key part of the evaluation of IE, but advances in 3D echocardiography have enabled a better spatial resolution and visualization of cardiac structures, allowing the identification of any valvular vegetations, abscesses, or nodules.[1]

Herein, we report the usefulness of 3D-TEE in a difficult diagnosis of catheter endocarditis hidden in intracaval stent.


  Case Report Top


We report the case of a 77-year-old female patient with a clinical history of paroxysmal atrial fibrillation in treatment with oral anticoagulant therapy, ischemic heart disease, obesity type I, diabetes mellitus type II, and chronic kidney disease.

In March 2013, she was hospitalized at the Gynecology Department due to ovarian cancer.

During hospitalization, due to worsening of kidney function, the patient performed hemodialysis treatment through tunneled central venous catheter (CVC) (13.5 Fr × 24 cm) in the right internal jugular vein.

In May 2015, she underwent percutaneous transluminal angioplasty and stenting of superior vena cava (SVC) for a thrombosis caused by CVC.

During one of these hemodialysis sessions, fever started to rise to 39.8°C, and a purulent-hematic material began to come out from the tunneling of the CVC. She had a neutrophil leukocytosis (15.85 × 103/μL) and an increased C-reactive protein (176 mg/L).

After obtaining informed consent, the patient performed the 2D-TTE which showed the presence of a rounded hyperechogenic mass (diameter 35 mm × 35 mm) at the right atrium roof likely referred to the stent and the CVC coming from the SVC [Figure 1].
Figure 1: Two-dimensional transthoracic echocardiography: apical 4-chamber view in systolic phase showing a rounded hyperechogenic mass (diameter 35 mm × 35 mm) of uncertain diagnosis at the right atrium roof (arrow)

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The TEE examination confirmed the diagnosis of the hemodialysis CVC hidden in the SVC stent since it raised from the SVC [Figure 2].
Figure 2: Transesophageal echocardiography: 5-chamber view in systolic phase showing hemodialysis central venous catheter hidden in the intracaval stent (arrow) in the right atrium, rising from the superior vena cava

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At the end, 3D-TEE was the really useful diagnostic tool showing the scaffold of the SVC stent partially dislocated in the right atrium [Figure 3]. The hemodialysis CVC, placed inside the SVC stent, showed irregular and augmented thickness (14 mm) of its surface referable to endocarditis vegetations [Figure 4]. Therefore, three hemocultures were performed from CVC and resulted positive for Staphylococcus aureus.
Figure 3: Three-dimensional transesophageal echocardiography: long axis view acquired around 105° showing the scaffold of the superior vena cava stent, partially dislocated in the right atrium, in which was placed the hemodialysis central venous catheter (arrow). RA = Right atrium

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Figure 4: Three-dimensional transesophageal echocardiography: 4 chamber view acquired at 0° showing hemodialysis central venous catheter, placed inside the superior vena cava stent with an irregular and augmented thickness (14 mm) of its surface (arrow) referable to endocarditis vegetation. RV = Right ventricle; LA = Left atrium; LV = Left ventricle

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The patient was treated with antibiotic therapy (daptomycin and piperacillin/tazobactam) and after 4 weeks of treatment, she underwent CVC extraction.


  Discussion Top


In this case report, we describe the useful role of 3D-TEE in the diagnosis of endocarditis vegetations on CVC hidden in an SVC stent.

In recent years, with an increasing number of central venous access procedures in oncology, renal failure, and nutrition, the incidence of infection of CVC has become more prevalent.[2]

Concerning the CVCs for hemodialysis, they are placed percutaneously into a large central vein, internal jugular, or subclavian vein, through the SVC with the goal of placing the tips of the catheter at the junction of the SVC and the right atrium.

CVCs afford the luxury of immediate access to the circulation without the requirement for cannulation; however, these devices are plagued by their propensity for infection and thrombosis, like in this case.

In this regard, IE may involve heart valves (native valve endocarditis), prosthetic valves (prosthetic valve endocarditis), and implanted devices [3],[4] and it is often deadly disease.[5],[6],[7]

The increased rates of CIED implantation and central venous access procedures, in older patients, with more comorbidities, have set the stage for higher rates of infection and the increasing frequency of IE in these patients.[8]

As in other forms of IE, echocardiography and blood cultures are the cornerstones of diagnosis.

Concerning the role of imaging, TEE may be useful in revealing catheters endocarditis and CIED infection in adults. Due to its poor sensitivity, TTE is frequently not helpful in ruling out a diagnosis of lead-related endocarditis, particularly in adults.[9],[10],[11] Vilacosta et al.[12] confirmed the superiority of TEE in the diagnosis of lead-dependent IE (LDIE).

The recent advent of 3D imaging has considerably enhanced TEE by providing relatively high image quality and several unique views, and by its capability to assess accurately intracardiac masses [13],[14],[15] and show intuitively understandable 3D images to physicians notspecialized in imaging.[16]

Indeed, in this case report, 3D-TEE allowed the diagnosis of vegetations on intracaval stent catheter in the right atrium. A prior visualization by X-plane allows the contemporary visualization of two orthogonal planes with high frame rate and is very useful in detecting hidden vegetations on devices. In this particular case, the 3D reconstruction gave good information on the characteristics of vegetation, despite the low frame rate.

However, the evaluation of patients with IE and LDIE include several other imaging techniques [3] such as multislice computed tomography, magnetic resonance imaging, 18F-fluorodeoxyglucose positron emission tomography/computed tomography, or other functional imaging modalities [16] that were not necessary in this case.


  Conclusion Top


Three-dimensional echocardiography is an important tool for aiding diagnosis or for fine-tuning a suspected diagnosis when traditional echocardiography is not completely clear for both medical and surgical decision-making.

In fact, in this case, 3D-TEE was useful for better detection of the relationship between the vascular stent and hemodialysis CVC and for diagnosis of endocarditis vegetations on CVC.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gonzalez YO, Ung R, Blackshear JL, Laman SM. Three-dimensional echocardiography for diagnosis of transcatheter prosthetic aortic valve endocarditis. Case 2017;1:155-8.  Back to cited text no. 1
    
2.
Surratt RS, Picus D, Hicks ME, Darcy MD, Kleinhoffer M, Jendrisak M, et al. The importance of preoperative evaluation of the subclavian vein in dialysis access planning. AJR Am J Roentgenol 1991;156:623-5.  Back to cited text no. 2
    
3.
Habib G, Lancellotti P, Antunes MJ, Bongiorni MG, Casalta JP, Del Zotti F, et al. 2015 ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J 2015;36:3075-128.  Back to cited text no. 3
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4.
Baddour LM, Epstein AE, Erickson CC, Knight BP, Levison ME, Lockhart PB, et al. Update on cardiovascular implantable electronic device infections and their management: A scientific statement from the American heart association. Circulation 2010;121:458-77.  Back to cited text no. 4
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5.
Thuny F, Grisoli D, Collart F, Habib G, Raoult D. Management of infective endocarditis: Challenges and perspectives. Lancet 2012;379:965-75.  Back to cited text no. 5
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6.
Habib G. Management of infective endocarditis. Heart 2006;92:124-30.  Back to cited text no. 6
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7.
Rundström H, Kennergren C, Andersson R, Alestig K, Hogevik H. Pacemaker endocarditis during 18 years in Göteborg. Scand J Infect Dis 2004;36:674-9.  Back to cited text no. 7
    
8.
Greenspon AJ, Patel JD, Lau E, Ochoa JA, Frisch DR, Ho RT, et al. 16-year trends in the infection burden for pacemakers and implantable cardioverter-defibrillators in the United States 1993 to 2008. J Am Coll Cardiol 2011;58:1001-6.  Back to cited text no. 8
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9.
Flachskampf FA, Badano L, Daniel WG, Feneck RO, Fox KF, Fraser AG, et al. Recommendations for transoesophageal echocardiography: Update 2010. Eur J Echocardiogr 2010;11:557-76.  Back to cited text no. 9
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10.
Golzio PG, Fanelli AL, Vinci M, Pelissero E, Morello M, Grosso Marra W, et al. Lead vegetations in patients with local and systemic cardiac device infections: Prevalence, risk factors, and therapeutic effects. Europace 2013;15:89-100.  Back to cited text no. 10
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11.
Vegas A. Three-dimensional transesophageal echocardiography: Principles and clinical applications. Ann Card Anaesth 2016;19:S35-43.  Back to cited text no. 11
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12.
Vilacosta I, Sarriá C, San Román JA, Jiménez J, Castillo JA, Iturralde E, et al. Usefulness of transesophageal echocardiography for diagnosis of infected transvenous permanent pacemakers. Circulation 1994;89:2684-7.  Back to cited text no. 12
    
13.
Galderisi M, Dini FL, Temporelli PL, Colonna P, de Simone G. Doppler echocardiography for the assessment of left ventricular diastolic function: methodology, clinical and prognostic value. Italian heart Journal 2004;5:86-97.  Back to cited text no. 13
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14.
De Luca I, Colonna P, Sorino M, Del Salvatore B, De Luca L. New monodimensional transthoracic echocardiographic sign of left atrial appendage function. J Am Soc Echocardiogr 2007;20:324-32.  Back to cited text no. 14
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De Luca I, Sorino M, De Luca L, Colonna P, Del Salvatore B, Corlianò L. Pre- and post-cardioversion transesophageal echocardiography for brief anticoagulation therapy with enoxaparin in atrial fibrillation patients: A prospective study with a 1-year follow-up. International Journal of Cardiology 2005;102:447-54.  Back to cited text no. 15
    
16.
Cecchi E, Ferro S, Forno D, Imazio M. Multimodality imaging of infective endocarditis in 2015 European society of cardiology guidelines. J Cardiovasc Echogr 2016;26:1-4.  Back to cited text no. 16
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


This article has been cited by
1 Diagnostic imaging in infective endocarditis: a contemporary perspective
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Expert Review of Anti-infective Therapy. 2020; : 1
[Pubmed] | [DOI]



 

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