Serial 18 F-fluorodeoxyglucose positron emission tomography/CT angiography in transcatheter-implanted aortic valve endocarditis

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A 75-year-old woman was referred to our centre for suspicion of endocarditis. Six months earlier, she had undergone an uncomplicated transcatheter aortic valve implantation (TAVI; Medtronic CoreValve Evolut R). For several days prior to admission, she had been experiencing symptoms of drowsiness, malaise, and a spiking fever. Blood cultures were positive for Staphylococcus aureus, and echocardiography revealed a small, slightly oscillating structure within the distal TAVI stent frame, without signs of perivalvular extensions or paravalvular leakage (Supplementary material online, Video S1). Additional cardiac computed tomography angiography (CTA) and 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) scans were performed in accordance with the most recent guidelines. Computed tomography angiography confirmed the presence of a small structure at the craniodorsal side of TAVI stent (Panel I-C), and demonstrated some stranding of the peri-aortic fatty tissue, slightly above the level of the suspected vegetation (Panel I-A; Supplementary material online, Figure S1), while PET revealed intense uptake of 18F-FDG in the same area (Panels I-B and I-D, Supplementary material online, Video S2; fused PET-CTA images shown). The maximum standardized uptake value (SUVmax; a quantitative measure of uptake) and the ratio between the SUVmax and the mean SUV in the bloodpool (target-to-background ratio, TBR) were 8.00 and 3.92, respectively (Supplementary material online, Figure S2, Panel A). The patient was treated conservatively and was started on flucloxacillin and gentamicin.

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