BACKGROUND Transesophageal echocardiography (TEE) remains the preferred test to rule out infective endocarditis (IE) but is resource intensive and carries risk. Multiple studies report low sensitivity of transthoracic echocardiography (TTE) for detection of IE; however, these studies did not account for TTE quality. We test the validity of a simple valve visualization grading tool to stratify TTEs by quality and determine whether a high-quality TTE may be used to exclude valvular vegetation and forgo the need for TEE. METHODS The Valve Visualization on Echocardiography Grade (VEG) tool scores the TTE from 0 to 10 based on leaflet visualization and valve leaflet clarity. The tool was retrospectively applied to 309 sequential patients who underwent both TTE and TEE at an academic teaching hospital between 2011 and 2015. The TEE report was the gold standard for presence or absence of vegetation. Patients with prosthetic valves and pacemaker wires were excluded. Sensitivity of TTE for detecting vegetation was calculated at each VEG score, and the optimal cutoff was identified. RESULTS A total of 309 patients were included in the analysis. Among the 216 negative TTEs, 19 (9%) had a positive TEE. The median VEG score was 4. A VEG score cutoff >6 provided optimal sensitivity and was used as the cutoff. Overall, 75 (25%) patients had a VEG score >6, and 234 (75%) had a score ≤6. Sensitivity and negative predictive value for IE were higher in the VEG >6 versus VEG ≤6 group (sensitivity 96% vs 66%, negative predictive value 97.5% vs 90%; P < .05). The false-negative rate was lower (2.5% vs 10%; P = .04) in VEG > 6 versus VEG ≤ 6 groups, respectively. CONCLUSIONS Leaflet visualization and valve leaflet clarity are important components in the TTE evaluation of patients with suspected IE. This study demonstrates that the better the valve leaflets are visualized on TTE (as represented in this population by a score >6), the higher the confidence one can have that the TTE will not be falsely negative for vegetation(s) when vegetation(s) are not noted on these TTEs. If validated in future prospective studies, this may reduce the need to perform an invasive TEE in selected patients undergoing evaluation for native valve IE.

中文翻译：

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在超声心动图分级工具上使用瓣膜可视化功能可提高经胸超声心动图排除天然瓣膜植被的敏感性和负预测价值。

背景技术经食道超声心动图检查（TEE）仍然是排除感染性心内膜炎（IE）的首选检查方法，但它是资源密集型且具有风险。多项研究报道经胸超声心动图（TTE）检测IE的敏感性较低；但是，这些研究并未说明TTE的质量。我们测试了一种简单的瓣膜可视化分级工具，以按质量对TTE进行分层的有效性，并确定是否可以使用高质量的TTE排除瓣膜植被并放弃对TEE的需求。方法：基于瓣膜可视化和瓣膜瓣清晰度，超声心动图瓣膜可视化（VEG）工具将TTE评分为0到10。该工具被追溯应用于2011年至2015年间在教学医院接受TTE和TEE治疗的309例连续患者。TEE报告是有无植被的金标准。排除有人工瓣膜和起搏器导线的患者。在每个VEG分数上计算TTE对植被检测的敏感性，并确定最佳临界值。结果分析共纳入309例患者。在216个阴性TTE中，有19个（9％）TEE阳性。VEG得分中位数为4。VEG得分临界值> 6提供了最佳灵敏度，并用作临界值。总体上，有75名（25％）患者的VEG评分> 6，而234名（75％）患者的VEG评分≤6。VEG> 6与VEG≤6组相比，IE的IE敏感性和阴性预测值更高（敏感性96％比66％，阴性预测值97.5％vs 90％； P <.05）。VEG> 6组和VEG≤6组的假阴性率分别较低（2.5％比10％； P = .04）。结论小叶可视化和瓣膜小叶清晰度是对可疑IE患者进行TTE评估的重要组成部分。这项研究表明，在TTE上瓣膜小叶的可视化效果更好（在该种群中以> 6的分数表示），当植被生长时，TTE对植被不会产生假阴性的置信度越高。这些TTE上未注明）。如果在未来的前瞻性研究中得到验证，这可能会减少对正在接受天然瓣膜IE评估的选定患者进行有创TEE的需求。当未在这些TTE上记录植被时，人们对TTE不会对植被造成假阴性的置信度越高。如果在未来的前瞻性研究中得到验证，这可能会减少对正在接受天然瓣膜IE评估的选定患者进行有创TEE的需求。当未在这些TTE上记录植被时，人们对TTE不会对植被产生假阴性的置信度越高。如果在未来的前瞻性研究中得到验证，这可能会减少对正在接受天然瓣膜IE评估的选定患者进行有创TEE的需求。