1. Journal of Nuclear Cardiology | Official Journal of the American Society of Nuclear Cardiology
Role of 18F-FDG PET/CT in the Diagnosis of Cardiovascular Implantable Electronic Device Infections: A Meta-Analysis
Maryam Mahmood MbChB1, Ayse Tuba Kendi MD2, Saira Farid MD1, Saira Ajmal MD1, Geoffrey B. Johnson MD PhD2,3, Larry M. Baddour MD1,4, Panithaya Chareonthaitawee MD4, Paul A. Friedman MD4, M. Rizwan Sohail MD1,4
1Division of Infectious Disease, Department of Medicine, 2Division of Nuclear Medicine, Department of Radiology, 3Department of Immunology, 4Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN USA
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2. Journal of Nuclear Cardiology | Official Journal of the American Society of Nuclear Cardiology
BACKGROUND
Cardiovascular implantable electronic device (CIED) infections can present as generator pocket infection, lead infection, CIED infective endocarditis (IE) which can involve a lead and/or a cardiac valve, or a combination of these syndromes1
Nuclear imaging is increasingly being used to assist in the diagnosis of CIED infections, particularly in the absence of localizing signs at the generator pocket or definitive echocardiographic findings
Fluorine 18 fluorodeoxyglucose (18F-FDG) positron-emission tomography (PET)/computed tomography (CT) in particular has demonstrated potential as an adjunctive diagnostic test in these challenging scenarios, with high diagnostic accuracy reported in small studies
Improving diagnostic certainty in CIED infections is important as current management guidelines recommend complete device removal for all patients with device infection due to the high risk of relapse with retained hardware1-3
Sohail MR et al. J Am Coll Cardiol, (18): p
Baddour LM et al. Circulation, (3): p
Deharo JC et al. Heart, (9): p
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3. METHODS Study type: Meta-analysis
Journal of Nuclear Cardiology | Official Journal of the American Society of Nuclear Cardiology
METHODS
Study type: Meta-analysis
Search: PubMed, Embase, Cochrane library, CINAHL, Web of Knowledge and were searched from January 1990 to April 2017 for eligible studies
Study endpoints: Accuracy of PET/CT in the diagnosis of CIED infection
Study variables: Sensitivity and specificity of PET/CT for diagnosis of CIED infection
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4. Summary of characteristics of studies
Journal of Nuclear Cardiology | Official Journal of the American Society of Nuclear Cardiology
Summary of characteristics of studies
Study
Setting
Participants
PET/CT protocol
Sensitivity/
Specificity
(95% CI)
Ahmed 2015 [6]
Prospective single center, England 46
4-6 hour fast, minute FDG uptake time
1.00 ( )
0.94 ( )
Bensimhon 2010 [7]
Prospective single center, France 21
8 hour fast, 60 minute FDG uptake time, blinded interpretation, results masked from clinician
0.85 ( )
1.00 ( )
Cautela 2013 [8]
8 hour fast, mean FDG uptake time 71 minutes (range )
0.70 ( )
1.00 ( )
Corrigan 2014 [31]
Retrospective single center, England 13
 Not stated
0.70 ( )
0.67 ( )
Granados 2016 [16]
Retrospective single center, Spain 29
12 hour fast, MS diet, 60 minute FDG uptake time, heparin bolus
1.00 ( )
1.00 ( )
Graziosi 2014 [9]
Prospective single center, Italy 27
45-60 minute FDG uptake time
0.67 ( )
0.87 ( )
Jimenez-Ballve 2016 [10]
Prospective single center, Spain 41
12 hour fast, MS diet, minute FDG uptake time, heparin bolus
0.91 ( )
0.00 ( )
Klug 2015 [11]
Prospective multicenter, France 79
Blinded interpretation
0.76 ( )
0.95 ( )
Leccisotti 2014 [12]
Prospective single center, Italy
15 hour fast, MS diet, blinded interpretation, final diagnosis based on microbiologic criteria
0.86 ( )
1.00 ( )
Pizzi 2015 [13] 28
12 hour fast, 60 minute FDG uptake time, heparin bolus
0.87 ( )
1.00 ( )
Ploux 2011
[14]
Retrospective single center, France 10
8 hour fast, 60 minute FDG uptake time
1.00 ( )
1.00 ( )
Remo 2014 [32]
Retrospective single center, USA 26
0.75 ( )
Sarrazin 2012 [15]
Prospective single center, Canada 42
8 hour fast, Mean FDG uptake time 65±17 minute
1.00 ( )
0.90 ( )
Tlili 2015 [17] 40
6 hour fast, 60 minute FDG uptake time
0.83 ( )
0.96 ( )
Insert a key table or a key figure If figure, insert legend
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5. Journal of Nuclear Cardiology | Official Journal of the American Society of Nuclear Cardiology
Overall, 14 studies involving 492 patients were included in the meta-analysis. The pooled sensitivity of PET/CT for diagnosis of CIED infection was 83% (95% CI, 78-86%) and the pooled specificity was 89% (95% CI, 84-94%).
Pooled sensitivity = 0.85 (0.80 to 0.89)
Chi-square = 40.90; df=13 (p=0.0001)
Inconsistency (1=square) = 68.2%
Pooled specificity = 0.90 (0.84 to 0.94)
Chi-square = 45.79; df=13 (p=0.0000)
Inconsistency (1=square) = 71.6%
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6. Journal of Nuclear Cardiology | Official Journal of the American Society of Nuclear Cardiology
CONCLUSIONS
Use of PET/CT in the evaluation of CIED infection demonstrates a high sensitivity of 85% and high specificity of 90%
PET/CT is a promising imaging modality as an adjunctive diagnostic tool in evaluating patients with suspected CIED infection
Larger prospective studies are needed to validate the optimal preparatory and imaging protocols for evaluation of CIED infections
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