Detection of endocarditis-associated perivalvular abscesses by two-dimensional echocardiography

The development of a perivalvular abscess as a complication of infective endocarditis adds appreciably to the expected morbidity and mortality of patients, but such abscesses are seldom recognized by available noninvasive techniques. Therefore, two-dimensional echocardio-graphic findings in 22 patients with perivalvular abscess found at surgery or necropsy were compared with those in 24 patients without abscess in a retrospective but blinded study. Forty-six valves were examined (31 aortic and 15 mitral, 35 prosthetic and 11 native); 4.0 ± 2.4 days (range 0 to 7) elapsed between echocardiography and surgery or necropsy.Patients with perivalvular abscess had a somewhat higher incidence of serious complications (emergency repeat valve replacement or death) than did patients with endocarditis alone (63 versus 35%, respectively, p < 0.05). No single echocardiography finding was frequently seen with a perivalvular abscess. A “typical” echo-free abscess was noted in only one patient; however, the presence of one or more of the following had a positive predictive value of 86% and a negative predictive value of 87% for the presence of perivalvular abscess: prosthetic valve rocking, sinus of Valsalva aneurysm, anterior aortic root thickness of 10 mm or greater, posterior aortic root thickness of 10 mm or greater or perivalvular density in a septum of 14 mm or greater. These predictive values, of course, apply only to patients with infective endocarditis going to surgery, and may assist the surgeon in knowing whether or not to expect an abscess. The predictive values might be expected to be somewhat smaller if all patients with infective endocarditis were studied, but the criteria may be valuable in the management of the patient before surgery.In 10 of the patients with documented perivalvular abscess, no valve mass was seen on echocardiography, but one of the five criteria for the diagnosis of an abscess was present. This suggests that the sensitivity of echocardiography for the detection of endocarditis itself may be increased by attention to these criteria