The relative roles of transthoracic compared with transesophageal echocardiography in children with suspected infective endocarditis.

OBJECTIVES: The study evaluated the additional benefit of transesophageal echocardiography (TEE) versus transthoracic echocardiography (TTE) in pediatric cases with suspected bacterial endocarditis.

BACKGROUND: In adult patients, TTE has a lower sensitivity and specificity than TEE for the detection of vegetations or aortic root abscess formation. Few data are available about the relative benefits of TEE over TTE in the pediatric age group.

METHODS: Patients were included if they had positive blood cultures for typical microorganisms and had a TTE and TEE within 14 days of each other. The patients had to meet the Duke criteria for a positive diagnosis of bacterial endocarditis. The TTE and TEE data were analyzed using the McNemar test for the significance of change.

RESULTS: Twenty-one patients fulfilled the criteria, at a median age of 9.5 years. Congenital heart disease was present in 13 patients; 4 patients were previously healthy and 4 patients had other medical problems. Nine patients had surgical confirmation of bacterial endocarditis. Fifteen patients had a positive cardiac finding, with 12 vegetations, 2 vegetations plus aortic root abscess, and 1 isolated abscess. There was excellent agreement between TTE and TEE in those cases with positive cardiac findings, with a p = 0.32, kappa 0.89. Using positive TEE cardiac findings as the gold standard, the sensitivity for TTE was 86% for all 15 events and 93% for the detection of a vegetation.

CONCLUSIONS: In pediatric cases, TTE has a high degree of sensitivity for the detection of supportive evidence of endocarditis, and TEE should be reserved for patients with a poor transthoracic window.