Adult Cardiac

FAIRFAX, VIRGINIA (March 11, 2024) - As use of prosthetic heart valves and implanted cardiac devices has increased, so too has the incidence of cardiovascular infection. While accurate diagnosis of this condition is critical for guiding treatment decisions that can prevent death and significant morbidity, current assessment strategies have proven insufficient. Recommendations released by 11 professional medical societies, including the Society of Thoracic Surgeons, detail a standardized approach for using PET/CT and SPECT/CT imaging to improve the evaluation and subsequent outcomes of patients with cardiovascular infection. The expert consensus statement – “18F-FDG PET/CT and Radiolabeled Leukocyte SPECT/CT Imaging for the Evaluation of Cardiovascular Infection in the Multimodality Context” – is published online in the Journal of Nuclear Cardiology, Clinical Infectious Disease, Heart Rhythm Journal, and JACC: Cardiovascular Imaging.

“The stakes are high with cardiovascular infection because the incidence is increasing and there is associated high morbidity and mortality,” says Jamieson M. Bourque, MD, MHS, FASNC, chair of the statement’s multisociety writing committee. “Other guidelines have recognized that FDG PET/CT and SPECT/CT imaging have high diagnostic accuracy with cardiovascular infection and can provide important information on the infection site, severity, cause, and whether the infection has spread outside the heart. This document does what others have not – it provides evidence-based consensus on specific clinical scenarios where FDG PET/CT and SPECT/CT add value for patient care in the context of robust multimodality imaging approaches available.”

Reflecting its multidisciplinary authorship, the statement emphasizes the complementary nature of advanced imaging modalities. It outlines the indications for echocardiography, cardiac computed tomography angiography, radiolabeled leukocyte SPECT/CT and 18F-FDG PET/CT in cardiovascular infection evaluation. The authors then provide a consensus-derived clinical indication rating of "appropriate," "may be appropriate," or "rarely appropriate" for use of 18F-FDG PET/CT and SPECT/CT in 73 clinical scenarios encompassing suspected native and prosthetic valve infective endocarditis, suspected cardiovascular implantable electronic device (CIED) infections, suspected prosthetic material infection, and suspected ventricular assist device (VAD) infection.

The expert consensus recommendations statement also includes:

• Diagnostic algorithmic flowcharts for suspected native or prosthetic valve infective endocarditis or prosthetic material/VAD infection and for suspected CIED infection;
• Teaching images from cases where 18F-FDG PET/CT and SPECT/CT studies were used in  prosthetic valve endocarditis, CIED pocket and lead infection, VAD infection and prosthetic material infection; and
• Teaching case examples where 18F-FDG PET/CT and SPECT/CT were used to assess prosthetic valve endocarditis, suspected lead CIED infection, suspected VAD infection and suspected prosthetic material infection.

“18F-FDG PET/CT and Radiolabeled Leukocyte SPECT/CT Imaging for the Evaluation of Cardiovascular Infection in the Multimodality Context” is the first document in the new American Society of Nuclear Cardiology Imaging Indications (ASNC I2) Series. Eleven partnering organizations participated in writing these recommendations and endorsed the document: The American Society of Nuclear Cardiology (ASNC), the American Association for Thoracic Surgery (AATS), the American College of Cardiology (ACC), the American Heart Association (AHA), the American Society of Echocardiography (ASE), the European Association of Nuclear Medicine (EANM), the Heart Rhythm Society (HRS), the Infectious Diseases Society of America (IDSA), the Society of Cardiovascular Computed Tomography (SCCT), the Society of Nuclear Medicine and Molecular Imaging (SNMMI) and the Society of Thoracic Surgeons (STS). The writing committee included representatives from each of the partnering organizations.

Read the consensus statement. 

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ABOUT ASNC

The American Society of Nuclear Cardiology and its 5,200 members have been improving cardiovascular outcomes through image-guided patient management for more than 30 years. As the leading society dedicated solely to the field of nuclear cardiology, ASNC establishes standards for excellence in cardiovascular imaging through the development of clinical guidelines, professional medical education, advocacy and research development. ASNC provides peer-reviewed original articles through its official publication, The Journal of Nuclear Cardiology. For more information, visit http://www.asnc.org.

ABOUT STS

Founded in 1964, The Society of Thoracic Surgeons is a not-for-profit organization representing more than 7,700 cardiothoracic surgeons, researchers, and allied healthcare professionals worldwide who are dedicated to ensuring the best possible outcomes for surgeries of the heart, lung, and esophagus, as well as other surgical procedures within the chest. The Society’s mission is to enhance the ability of cardiothoracic surgeons to provide the highest quality patient care through education, research, and advocacy.

Shortly after the 60th STS Annual Meeting began, a packed crowd attended the "Trends and Research from the STS Adult Cardiac Surgery Database (ACSD)" session, beginning with a presentation by Michael E. Bowdish, MD, of the Smid Heart Institute, Cedars-Sinai Medical Center. He looked back at the origins of the ACSD, which was established in 1989 to collect information on cardiac surgery procedures, track outcomes, and provide insights into opportunities for quality improvement. 

Today – more than three decades later – the Database offers more than nine million recorded procedures making it one of the most comprehensive, robust, and sophisticated contemporary clinical databases in use.   

For example, 95% of centers performing coronary artery bypass grafting (CABG) in the United States, and 97% of patients receiving CABG are included in the STS ACSD. Every year 10% of the participating sites undergo a data audit assessing data accuracy and completeness with strict thresholds to pass quality control. Continuous education of data managers is a further element to ensure data quality. 

"STS ACSD is a vital source of data for outcomes research quality improvement, with overall volumes that are stable with notable trends in aortic surgery," said Dr. Bowdish.

The STS ACSD has provided the foundation for national benchmarking in adult cardiac surgery through the development of regularly updated and recalibrated risk models and performance metrics, the availability of feedback reports to database participants and individual surgeons, quality-improvement efforts, voluntary public reporting, and comparative effectiveness research. 

On day one of STS 2024, meeting goers attended numerous sessions that explored the growing debate between SAVR and TAVR as treatment options,

"Improved Longitudinal Outcomes with Surgical Aortic Valve Replacement with Atrial Fibrillation Management over Transcatheter Aortic Valve Replacement Alone," part of the larger "Bring SAVR Back" session given by J Hunter Mehaffey, MD, unveiled Class I guideline recommendations that support atrial fibrillation (AF) treatment during surgical aortic valve replacement (SAVR). And how recently, many low to intermediate risk patients with AF and aortic stenosis (AS) are managed by transcatheter aortic valve replacement (TAVR). And finally, they evaluated real-world longitudinal outcomes of TAVR vs SAVR with or without AF treatment. 

"We concluded that in Medicare beneficiaries with AF who required aortic valve replacement, SAVR with concomitant treatment of AF was associated with improved longitudinal survival and freedom from stroke compared to TAVR," noted Dr. Mehaffey. "Consideration should be given for SAVR with AF treatment as a first-line approach for patients with AF requiring aortic valve replacement." 

In his discussion of "Robotic Aortic Valve Replacement versus Transcatheter Aortic Valve Replacement: A Propensity Matched Analysis," Vikrant Jagadeesan, MD, presented findings on contemporary data that supports equipoise between surgical aortic valve replacement and transcatheter aortic valve replacement (TAVR) for the management of symptomatic severe aortic stenosis (AS). He further explained that controversy exists around the optimal management of patients in low to intermediate risk categories, and how the study compared outcomes of surgical robotic aortic valve replacement (RAVR) to TAVR. 

"Compared to TAVR, RAVR was associated with lower stroke and PPM rates, less PVL, and improved 1 year survival," said Dr. Jagadeesan. "And RAVR may provide a safe and effective minimally invasive first-line alternative for low to intermediate risk patients presenting with symptomatic AS."

In a late breaking session titled, "Cardiac Surgery after Transcatheter Aortic Valve Replacement: Trends and Outcomes," Michael Bowdish, MD, illustrated how his research team set out to document trends and outcomes in cardiac surgery following transcatheter aortic valve replacement (TAVR), a topic gaining importance as reports of subsequent cardiac operations and early TAVR explantations increase. Using the Society of Thoracic Surgeons Adult Cardiac Surgery Database, the study covers adult patients who underwent cardiac surgery after an initial TAVR from January 2012 to March 2023. 

"The study findings underscore the escalating need for both aortic and non-aortic valve cardiac surgeries following TAVR," explained Dr. Bowdish. "They note a substantial increase in the frequency of these surgeries, emphasizing the importance of understanding outcomes."  He observed elevated risk in these cases, as indicated by mortality and stroke rates, which calls for careful consideration, particularly given the expanding use of TAVR across a broader range of age and risk profiles. Finally, the study suggests the need for ongoing assessment and longitudinal evidence to inform decision-making in the evolving landscape of TAVR applications.