(Radiology. 2000;217:263-269.)
© RSNA, 2000
Infectious Pseudoaneurysms Suspected at Echocardiography: Electron-Beam CT Findings1
Patricia Ugolini, MD,
Elie Mousseaux, MD, PhD,
Anne Hernigou, MD and
Jean-Claude Gaux, MD
1 From the Department of Radiology, Hopital Broussais, Paris, France (P.U., E.M., A.H., J.C.G.), and INSERM U494, Institut National de la Santé et de la Recherche Médicale, Paris, France (P.U., E.M.). From the 1999 RSNA scientific assembly. Received August 9, 1999; revision requested September 1; revision received December 13; accepted December December 21. Address correspondence to E.M., Hopital Européen Georges Pompidou, 20 rue Leblanc, 75908 Paris Cedex 15, France (e-mail: elie.mousseaux@egp.ap-hop-paris.fr).
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ABSTRACT
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PURPOSE: To review the electron-beam computed tomographic (CT) findings in patients with clinical endocarditis and suspected of having perivalvular pseudoaneurysms at echocardiography and to compare these findings with echocardiographic data.
MATERIALS AND METHODS: Data on 17 patients who underwent electron-beam CT for suspicion of perivalvular infectious pseudoaneurysm at echocardiography were retrospectively reviewed. Thirteen patients had a history of valvular surgery. Electron-beam CT findings—lesion size, number, extent, and relationships with surrounding structures, and associated lesions—were compared with echocardiographic and surgical and/or autopsy data.
RESULTS: In all patients, electron-beam CT depicted one or more abnormal cavities that filled with contrast material after bolus injection. The mean size (3.5 cm) and number (n = 21) of pseudoaneurysms recorded with electron-beam CT were greater than those recorded with echocardiography (2.9 cm and n = 13, respectively). Associated electron-beam CT findings included valvular vegetations in three patients; mediastinitis in two; and coronary arterial involvement in six. In eight (47%) patients, electron-beam CT depicted a pseudoaneurysm or an additional pseudoaneurysm that was only suspected—not depicted—at echocardiography. Transthoracic and transesophageal echocardiography resulted in underestimation of lesion number, size, and extent and associated lesions, particularly in patients with valvular prostheses or voluminous lesions.
CONCLUSION: Thoracic infectious pseudoaneurysms are well depicted with electron-beam CT, which may be a useful addition to echocardiography for detection of this disease and thus help in preoperative planning.
Index terms: Computed tomography (CT), electron beam, 50.12111, 50.12112, 50.12114 • Endocarditis, 53.219 • Heart, CT, 50.12111, 50.12112, 50.12114 • Heart, diseases, 53.219 • Heart, surgery, 53.45 • Heart, valves, 53.219
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INTRODUCTION
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Perivalvular abscesses are seen in about 30% of patients with bacterial endocarditis. It is important to detect these lesions, because they indicate advanced disease that has a poor prognosis and thus necessitates aggressive medical management and sometimes surgery. Transesophageal echocardiography (TEE) is the method of choice for detecting infective endocarditis of both native and prosthetic cardiac valves (1–3). This technique also aids in the detection of complications, such as perivalvular abscesses and pseudoaneurysms, with good sensitivity (80%–87%) and specificity (95%–98%) (2–4). The technique is currently used in clinical practice for the diagnosis and follow-up of infectious pseudoaneurysms. However, transthoracic echocardiographic (TTE) and TEE exploration of the perivalvular region can be limited by artifacts induced by valvular prostheses (5), and optimal visualization with these techniques can be restricted in certain anatomic regions, such as the right cavities, cardiac apex, and mediastinum. Furthermore, with TTE and TEE examinations, one cannot optimally explore the retrosternal or pleural space and the pulmonary parenchyma. Thus, some patients suspected of having perivalvular pseudoaneurysms need to be examined with a complementary method.
There have been reports (5–8) of isolated cases involving a few patients (three to five) with infectious pseudoaneurysms who were examined by using magnetic resonance (MR) imaging or computed tomography (CT). However, few data are available on the appearance of such lesions at tomographic imaging and on the contribution of this modality in a larger number of patients.
Electron-beam CT provides 100-msec electrocardiographically gated sections and cardiac images of good quality without motion artifacts. This technique has been shown to be useful in the diagnosis of many heart and great-vessel diseases. But, to the best of our knowledge, its contribution to the diagnosis of infectious perivalvular pseudoaneurysms had not been investigated before the present study. The purpose of this study was to review the findings obtained by using electron-beam CT in patients with clinical endocarditis who were suspected of having perivalvular pseudoaneurysms at echocardiography and compare these data with the echocardiographic findings.
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MATERIALS AND METHODS
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Seventeen consecutive patients (seven women, 10 men; mean age, 55 years; age range, 25–83 years) were referred to our radiology department for electron-beam CT between January 1993 and July 1999. They all had previously or recently had endocarditis, and their echocardiographic findings, which were interpreted with transthoracic and multiplanar transesophageal approaches by an experienced echocardiographer, indicated suspected perivalvular pseudoaneurysm. The maximum delay between echocardiography and electron-beam CT did not exceed 36 hours. Thirteen (76%) patients had undergone cardiac valvular surgery, and six had a history of proved endocarditis. Blood cultures from 12 patients were positive for endocarditis at the time of electron-beam CT. The electron-beam CT findings were confirmed at surgery or autopsy in 11 patients. The characteristics and outcomes of all the patients are listed in Tables 1 and 2.
All examinations were performed by using the same electron-beam CT scanner (model C-100; Imatron, San Francisco, Calif). Baseline studies were performed in all patients by obtaining two series of nonenhanced and contrast material–enhanced contiguous scans from the aortic arch to the diaphragm. The contrast-enhanced studies were performed with injection of a nonionic contrast medium by using a power injector and an injection rate of 2–3 mL/sec; the images were acquired during the arterial phase. For contrast-enhanced CT imaging, 3-mm-thick contiguous sections were acquired by means of continuous volume scanning in three patients and in an electrocardiographically triggered mode in 14 patients. The acquisition time was 100 msec per section. Additional cardiac cine-mode acquisitions in long- or short-axis views were obtained in five patients. Delayed phase images were obtained in three patients. The initial acquisitions in all the patients were reformatted as three-dimensional images by using a dedicated workstation. In one patient, two different electron-beam CT examinations were performed with a 15-day interval between the studies.
All the electron-beam CT studies were reviewed by two radiologists (E.M., A.H.) with consensus opinion. For each patient, the precise location of the pseudoaneurysms; the number, size (defined by using the mean of the three spatial dimensions), and extent of the lesions; and the relationships of the lesions with surrounding structures were assessed and compared with the contemporary TTE and TEE data. Associated electron-beam CT findings also were recorded. The clinical data on all the patients, as well as the surgical and/or autopsy findings, when available, were reviewed.
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RESULTS
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Electron-Beam CT Findings
The echocardiographic and electron-beam CT findings are summarized in Tables 2 and 3. High-quality electron-beam CT images were obtained in all patients and demonstrated one or more abnormal circulating cavities of various sizes (5–80 mm) that filled with contrast material after bolus injection (Fig 5). In one patient, the first electron-beam CT examination revealed only a periprosthetic thickening, but this subsequently progressed to form two circulating cavities 15 days later. These findings were confirmed at surgery. TTE and TEE depicted only the posterior cavity in this patient (Fig 1).
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Figure 1a. Patient 5. Transverse contrast-enhanced electron-beam CT images obtained at the level of the aortic root in a 58-year-old man who had undergone aortic and mitral valve replacement. In a and b, AA = ascending aorta, DA = descending aorta, FA = false aneurysm, LA = left atrium, LV = left ventricle, RV = right ventricle, SCV = superior vena cava. (a) The initial CT image demonstrated only perivalvular thickening (arrowheads). (b) The CT image obtained 15 days later at the same level revealed two pseudoaneurysmal cavities (arrows). Contemporary TEE did not depict the anterior pseudoaneurysm.
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Figure 1b. Patient 5. Transverse contrast-enhanced electron-beam CT images obtained at the level of the aortic root in a 58-year-old man who had undergone aortic and mitral valve replacement. In a and b, AA = ascending aorta, DA = descending aorta, FA = false aneurysm, LA = left atrium, LV = left ventricle, RV = right ventricle, SCV = superior vena cava. (a) The initial CT image demonstrated only perivalvular thickening (arrowheads). (b) The CT image obtained 15 days later at the same level revealed two pseudoaneurysmal cavities (arrows). Contemporary TEE did not depict the anterior pseudoaneurysm.
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Figure 2. Patient 8. Transverse contrast-enhanced electron-beam CT images obtained at four levels (A-D) through the aortic root in an 83-year-old woman with a calcified degenerated native aortic valve. TTE and TEE depicted only a noncirculating abscess along the posterior wall of the aortic root, extending posteriorly to the annulus. A thrombosed pseudoaneurysm, or false aneurysm (FA, straight arrows), partly located at the upper anterior part of the aortic annulus, in contact with the left coronary artery (curved arrows), was confirmed at electron-beam CT. AA = ascending aorta, DA = descending aorta, LA = left atrium, LV = left ventricle, RV = right ventricle, SCV = superior vena cava.
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Figure 3. Patient 9. Transverse contrast-enhanced electron-beam CT images obtained at four levels (A-D) through the aortic root in a 44-year-old woman demonstrate a voluminous pseudoaneurysmal cavity, or false aneurysm (FA, arrowheads), originating from the right border of the aortic root. The left coronary artery (curved arrow) arises at the same level. Note the right coronary arterial involvement (open arrow) by the pseudoaneurysm and the thrombus (solid straight arrow) floating in the aortic lumen. AA = ascending aorta, DA = descending aorta, LA = left atrium, LV = left ventricle, RV = right ventricle.
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Figure 4a. Patient 11. In a and b, AA = ascending aorta, DA = descending aorta, FA = false aneurysm, LA = left atrium, LV = left ventricle, PA = pulmonary artery, RV = right ventricle, SCV = superior vena cava. (a) Transverse contrast-enhanced electron-beam CT image obtained at the level of the aortic outflow track in a 75-year-old woman who had Staphylococcus-related septicemia and had undergone aortic valve replacement. Vegetations (arrowhead) are seen on the aortic valve leaflets, and there is a small posterior pseudoaneurysm, or false aneurysm (arrow). (b) Coronal-oblique CT image reformatted with acquisition data from a shows a second pseudoaneurysmal cavity, or false aneurysm (arrow) situated superiorly along the right border of the aortic root. This pseudoaneurysm initially was not seen at TEE.
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Figure 4b. Patient 11. In a and b, AA = ascending aorta, DA = descending aorta, FA = false aneurysm, LA = left atrium, LV = left ventricle, PA = pulmonary artery, RV = right ventricle, SCV = superior vena cava. (a) Transverse contrast-enhanced electron-beam CT image obtained at the level of the aortic outflow track in a 75-year-old woman who had Staphylococcus-related septicemia and had undergone aortic valve replacement. Vegetations (arrowhead) are seen on the aortic valve leaflets, and there is a small posterior pseudoaneurysm, or false aneurysm (arrow). (b) Coronal-oblique CT image reformatted with acquisition data from a shows a second pseudoaneurysmal cavity, or false aneurysm (arrow) situated superiorly along the right border of the aortic root. This pseudoaneurysm initially was not seen at TEE.
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Figure 5a. Patient 16. Transverse contrast-enhanced electron-beam CT images of a pseudoaneurysmal cavity in a 39-year-old woman who had previously undergone surgery for correction of a Fallot tetralogy, with a patch of the right ventricle. In a and b, AA = ascending aorta, DA = descending aorta, FA = false aneurysm, LA = left atrium, LV = left ventricle, PA = pulmonary artery, RA = right atrium, RV = right ventricle, SCV = superior vena cava. (a) The pseudoaneurysmal cavity, or false aneurysm (arrowheads) originates from the tricuspid annulus and extends over the anterior wall of the right ventricle within the pericardium; it filled with contrast material after bolus injection. Note also the pericardial effusion (arrow) in contact with the pseudoaneurysm, which was not seen at echocardiography. (b) The false aneurysm in a is associated with an abnormal anterior mediastinal collection (curved arrows) with air, contrast material, and fluid attenuation.
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Figure 5b. Patient 16. Transverse contrast-enhanced electron-beam CT images of a pseudoaneurysmal cavity in a 39-year-old woman who had previously undergone surgery for correction of a Fallot tetralogy, with a patch of the right ventricle. In a and b, AA = ascending aorta, DA = descending aorta, FA = false aneurysm, LA = left atrium, LV = left ventricle, PA = pulmonary artery, RA = right atrium, RV = right ventricle, SCV = superior vena cava. (a) The pseudoaneurysmal cavity, or false aneurysm (arrowheads) originates from the tricuspid annulus and extends over the anterior wall of the right ventricle within the pericardium; it filled with contrast material after bolus injection. Note also the pericardial effusion (arrow) in contact with the pseudoaneurysm, which was not seen at echocardiography. (b) The false aneurysm in a is associated with an abnormal anterior mediastinal collection (curved arrows) with air, contrast material, and fluid attenuation.
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At electron-beam CT, pseudoaneurysms were found in contact with aortic and mitral prostheses in 14 cases and originating from the ascending aorta in five cases, from the anterior wall of the right ventricle in one case, and from the posterior wall of the left ventricle in one case. The associated electron-beam CT findings were as follows: pseudoaneurysm in contact or involved with one coronary artery (Fig 3) in six patients, calcified or noncalcified vegetations (Fig 4) in three patients, evidence of mediastinitis or mediastinal abscess (Fig 5) in two patients, and extension into the retrosternal space with sternal osteitis in one patient. These electron-beam CT findings were confirmed in the two cases of mediastinal abscess and in five of the six patients with pseudoaneurysms in contact or involved with one coronary artery (Figs 2, 3) at surgery or autopsy. In one patient, the cine-mode acquisitions enabled better visualization of the origin of the pseudoaneurysm in the left ventricle.
Comparison of Electron-Beam CT and Echocardiographic Findings
In eight (47%) of the 17 patients, electron-beam CT provided additional information regarding the number and size of the pseudoaneurysmal cavities in addition to that obtained with echocardiography. Echocardiography demonstrated a total of 13 pseudoaneurysmal cavities, whereas electron-beam CT depicted a total of 21 cavities. Additional pseudoaneurysmal cavities were demonstrated at electron-beam CT in three patients with valvular prostheses. Electron-beam CT depicted one pseudoaneurysm in five patients in whom a lesion was suspected but not depicted at echocardiography because of the clinical context of endocarditis. In particular, two supplementary lesions were found in contact with the anterior border of the aortic prosthesis, and three additional pseudoaneurysms were detected within the wall of the aortic root, a far distance from the valve. At echocardiography, right ventricular involvement of the pseudoaneurysm was always missed, whereas left ventricular involvement was detected in only two of three patients.
In one patient, electron-beam CT helped determine the cause of the extrinsic compression of the right ventricle seen at TTE by depicting a large pseudoaneurysm of the right ventricle that was not seen by using echocardiography (Fig 5). Three other large pseudoaneurysms, one along the right ventricular outflow track and the other along the inferior wall of the left ventricle, also were not depicted by either TTE or TEE.
The mean size of lesions recorded by using electron-beam CT was 3.5 cm versus a mean size of 2.9 cm at echocardiography. The superior limit of the pseudoaneurysmal cavities was the dimension that was least well assessed with echocardiography (Fig 2). Thus, the relationship between the pseudoaneurysm and the coronary arteries was never demonstrated at echocardiography. Electron-beam CT demonstrated a mediastinal extension of the infectious process in two patients and a close relationship between a voluminous aortic pseudoaneurysm and the retrosternal space, with sternal osteitis, in another patient. Echocardiography with Doppler analysis depicted periprosthetic regurgitation in five patients and valvular vegetation in eleven.
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DISCUSSION
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The study results presented herein show that electron-beam CT can depict infectious pseudoaneurysms, even when they are only suspected at echocardiography or when the lesions are small (5 mm), and in patients with valvular prostheses. Electron-beam CT can also precisely demonstrate the extension of such pseudoaneurysmal lesions and their relationships with coronary arteries and with surrounding thoracic structures, especially when the lesions are voluminous. It can also depict additional abnormalities. Infectious pseudoaneurysms due to endocarditis are still considered to be serious, life-threatening lesions that are associated with a high mortality rate (9). The hospital mortality rate is about 10% higher for patients with both endocarditis and perivalvular abscesses (2), and four (24%) of our 17 study patients died during the active phase of the disease.
When used with a multiplanar approach, TEE is a useful and much more sensitive method for the detection of perivalvular pseudoaneurysms (ie, abscesses) than TTE. However, the overall sensitivity of TEE for detecting pseudoaneurysm varies from 80% to 87% (1–4). There is also a nonnegligible rate of false-negative TEE studies in patients with a prosthetic valve or annular calcifications because of the acoustic shadowing created by the prosthesis or the calcifications, particularly when the anterior periaortic area is explored (2). This is confirmed by data in the current series, in which electron-beam CT depicted additional pseudoaneurysmal cavities in three patients with a valvular prosthesis; two of these cavities were in the anterior aortic region (Figs 1, 4).
Optimal visualization with TTE and TEE is restricted in certain anatomic regions, such as the left ventricular apex and the cavities on the right side of the heart (10). In five patients in this series, TTE and TEE failed to depict the pseudoaneurysms that arose from the free wall (n = 1) and/or the outflow track (n = 3) of the right ventricle (Fig 5) and from the posterior wall of the left ventricle (n = 1). In addition, TEE examinations cannot be performed in some patients for various reasons, including esophageal disease and severe cervical arthrosis.
We found that electron-beam CT depicted more pseudoaneurysmal cavities than did TEE. Diagnostic electron-beam CT examinations were performed in all patients, including the 13 patients who had a prosthesis or, in cases of annular calcifications, only a few beam-hardening artifacts, as illustrated in Figures 1, 2, and 4. The rapid scanning time (100 msec) of electron-beam CT enables good exploration of the perivalvular area and the production of images without motion artifacts.
However, this was a retrospective study, and we could not compare the specificity and sensitivity of electron-beam CT for the detection of infectious pseudoaneurysms with those of echocardiography. The number of patients who had undergone surgery (13 of 17 [76%]) in this series might be indicative of a bias in the selection of patients. Few data on patients with native valvular endocarditis (n = 4) were studied, and further investigation is needed to assess the potential of electron-beam CT in such patients. Thus, a prospective study should be conducted to assess the real accuracy of electron-beam CT for detecting infectious pseudoaneurysms.
Some authors (5,6) have suggested that MR imaging can be used to detect perivalvular abscesses or pseudoaneurysms. MR imaging has the advantage of being multiplanar, and it can be performed without contrast material. However, the spatial resolution obtained by using MR imaging is inferior to that with TEE or electron-beam CT in regions close to the center of the thorax. Artifacts due to valvular prostheses also can degrade these images, particularly when gradient-echo sequences are used. Finally, MR imaging cannot be performed in patients who have pacemakers.
The detection of infectious pseudoaneurysm in patients with endocarditis can substantially alter clinical and surgical management. Some have proposed that early surgical treatment plus antibiotic therapy be used to prevent widespread tissue destruction and improve outcome (10). However, this protocol remains controversial, and others advocate surgery only in patients with persistent signs of infection despite appropriate antibiotic treatment or in those with advanced heart failure.
Some information that is essential for preoperative planning, such as the relationships between the pseudoaneurysm and the retrosternal space, the pseudoaneurysm and the remaining mediastinum, and the pseudoaneurysm and the coronary arteries, cannot be obtained by using either TTE or TEE. The advantages of tomographic imaging in the follow-up of sternal infections, to visualize the relationship of the aorta with the sternum and the retrosternal space, have been pointed out by some authors (11). The retrosternal involvement in this clinical setting is particularly important, because the surgeon must determine the approach to use for extracorporeal circulation (eg, femoral-femoral bypass) (12). Electron-beam CT provided these important presurgical data in three of our study patients (Fig 5).
The possibility for subsequent multiplanar reformatting is another advantage of electron-beam CT, because this provides a much clearer and complete understanding of the extent and relationships of large lesions. The field of view explored by using TEE at one anatomic level is limited, and the three-dimensional representation of large lesions may be difficult. In adults, upper transthoracic visualization with TTE may be restricted by pulmonary parenchyma. These factors may help explain the underestimated numbers, sizes, and extents of detected lesions with echocardiography in our study patients.
In addition, demonstrating the involvement of the coronary arteries may greatly modify the surgical approach in patients with infectious pseudoaneurysm (13). Although TEE can enable visualization of the proximal coronary arteries, it did not enable identification of their involvement or their close relationship with pseudoaneurysms in six patients, whereas electron-beam CT did (Figs 2, 3). All these additional features of electron-beam CT, particularly the greater number of detected lesions and the depiction of the relationships between the pseudoaneurysm and the coronary arteries, substantially contributed to the preoperative planning for the patients. Thoracic electron-beam CT is now routinely used with echocardiographic exploration at our institution when surgery is considered for patients with endocarditis and pseudoaneurysm. Electron-beam CT studies should be performed also in patients with valvular prostheses and persistent febrile symptoms and in whom TTE and TEE examinations were negative, particularly in postoperative cases. Simultaneous exploration of the lung, pleura, mediastinum, and upper part of the abdomen, which often aids in identifying the causative factor, is another advantage of electron-beam CT.
Electron-beam CT, however, does not accurately depict valvular vegetation or prosthesis-related thrombosis. Echocardiography provided useful data on valvular function, as was the case in five patients in this series, in whom substantial periprosthetic regurgitation was detected by using TEE. Thus, these two techniques appear to be complementary and to enable a complete evaluation of this disease.
Infectious perivalvular pseudoaneurysms can be detected by using electron-beam CT. The results of this study suggest that this imaging technique complements the traditional echocardiographic approach for planning cardiac surgery, especially in patients with valvular prostheses, suspected endocarditis after negative echocardiographic results, and voluminous lesions. Although electron-beam CT is not widely used, spiral CT has been reported to be useful for diagnosing infectious pseudoaneurysms in isolated cases (7,14). Fast spiral CT with multidetectors reduces acquisition times and thus permits cardiac electrocardiographic gating, and it may be promising for the diagnosis of infectious pseudoaneurysms.
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FOOTNOTES
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Abbreviations: TEE = transesophageal echocardiography,
TTE = transthoracic echocardiography
Author contributions: Guarantors of integrity of entire study, E.M., P.U.; study concepts and design, E.M., P.U.; definition of intellectual content, E.M., P.U., A.H.; literature research, P.U., E.M.; clinical studies, E.M., A.H., P.U.; data acquisition, E.M., A.H.; data analysis, P.U., E.M.; manuscript preparation and editing, P.U., E.M.; manuscript review, all authors.
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REFERENCES
|
|---|
-
Daniel WG, Schroder E, Nonnast-Daniel B, Lichtlen PR. Conventional and transesophageal echocardiography in the diagnosis of infective endocarditis. Eur Heart J 1987; 8:287-292.
-
Daniel WG, Mugge A, Martin RP, et al. Improvement in the diagnosis of abscesses associated with endocarditis by transesophageal echocardiography. N Engl J Med 1991; 324:795-780.[Abstract]
-
Thomas D, Desruennes M, Jault F, Isnard R, Gandjbakhch I. Cardiac and extracardiac abscesses in bacterial endocarditis. Arch Mal Coeur Vaiss 1993; 86:1825-1835[French].[Medline]
-
Tingleff J, Egeblad H, Gotzsche CO, et al. Perivalvular cavities in endocarditis: abscesses versus pseudoaneurysm—a transesophageal Doppler echocardiographic study in 118 patients with endocarditis. Am Heart J 1995; 30:93-100.
-
Winkler ML, Higgins CB. MRI of perivalvular infectious pseudoaneurysms. AJR Am J Roentgenol 1986; 147:253-256.[Abstract/Free Full Text]
-
Akins WE, Slone RM, Wiechmann BN, Browning M, Martin TD, Mayfield WR. Perivalvular pseudoaneurysm complicating bacterial endocarditis: MR detection in five cases. AJR Am J Roentgenol 1991; 156:1155-1158.[Abstract/Free Full Text]
-
Sullivan KL, Steiner RM, Smullens SN, Griska L, Meister SG. Pseudoaneurysm of the aorta following cardiac surgery. Chest 1988; 93:138-143.[Abstract/Free Full Text]
-
Berrizbeitia LD, Anderson WA. Ultrafast computed tomography in infectious pseudoaneurysm of the left ventricular outflow tract. J Thorac Cardiovasc Surg 1997; 114:138-139.[Free Full Text]
-
Arnett EN, Roberts WC. Prosthetic valve endocarditis: clinicopathologic analysis of 22 necropsy patients with comparison observations in 74 necropsy patients with active infective endocarditis involving natural left-sided cardiac valves. Am J Cardiol 1976; 38:281-292.[Medline]
-
Croft CH, Woodward W, Elliot A, Commerford PJ, Barnard CN, Beck W. Analysis of surgical versus medical therapy in active complicated native valve infective endocarditis. Am J Cardiol 1983; 51:1650-1655.[Medline]
-
Goodman LR, Kay HR, Teplick SK, Mundht E. Complications of median sternotomy: computed tomographic evaluation. AJR Am J Roentgenol 1983; 141:225-230.[Abstract/Free Full Text]
-
Suen HC, Barner HB. Repair of right ventricular rupture complicating mediastinitis. Ann Thorac Surg 1998; 66:2115-2116.[Abstract/Free Full Text]
-
Abe T, Sugiki K, Komatsu S. Successful surgical treatment of prosthetic valve endocarditis and aortic root abscesses. Chest 1984; 85:832-834.[Abstract/Free Full Text]
-
Otto R, Henderson R, Dandekar N. MR and CT findings in infected ventricular repair. J Comput Assist Tomogr 1987; 11:1069-1070.[Medline]
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ABSTRACT
INTRODUCTION
