EDITORIAL
Editorial
Radionuclide Imaging for the
Detection of
Cardiac Infection
Dan-Bing Zhou, MD and Nathan Better, MBBS, FRACP∗
Department of Nuclear Medicine and Department of Cardiology,
Royal Melbourne Hospital, Parkville, Victoria 3050, Australia
T he current techniques for localizing cardiac infec-
tion involve two imaging strategies. Firstly, anatom-
ical changes in tissue can be visualised by X-ray,
computed tomography (CT), echocardiography and mag-
netic resonance imaging (MRI). Secondly, physiologi-
cal change can be identified by radionuclide imaging,
such as gallium-67 citrate scintigraphy, labelled leuko-
cyte scintigraphy or even labelled antibodies. Gallium-
67 citrate, indium-111 and technetium-99 m-labelled
leukocytes and technetium-99 m-labelled antigranulocyte
monoclonal antibody Fab’ fragments (LeukoScan) are ap-
proved agents for imaging of infection in the United
States.1
Anatomical Imaging
Traditionally, anatomical imaging, especially echocardio-
graphy, plays a first line role in the diagnosis of cardiac
infection together with blood cultures. It provides infor-
mation such as assessment of a pericardial collection, a
cardiac abscess or of valvular vegetations. The sensitivity
and the specificity of transoesophageal echocardiography
for detecting endocarditis and its complications were
80 and 95% in Thomas’s study.2 Another study showed
the sensitivity is about 94% but the specificity is 65%.3
Transthoracic echocardiography, CT and MRI are less
sensitive than transoesophageal echocardiography2,3
but remain slightly less invasive options. In a recent
statement by the American Heart Association,4 all these
technologies were recommended in the assessment of
nonvalvular cardiovascular device-related infections,
including pacemakers. Of course, extreme caution
must be exercised in performing MRI in such patients
depending on the type of device and potential risk to
the patient. In this statement, radionuclide imaging is
recommended for consideration in the more difficult
cases.
∗ Corresponding author. Tel.: +61-3-9342-7480;
fax: +61-3-9342-7342.
E-mail address: nathan.better@mh.org.au (N. Better).
© 2004 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of
Australia and New Zealand. Published by Elsevier Inc. All rights reserved.
Radionuclide Imaging
Radionuclide imaging is also a useful, non-invasive tech-
nique for evaluating cardiac infection. Because of its de-
tection of physiological change, which may occur prior
to anatomical alteration, it can provide information at an
early stage.
The mechanisms of gallium-67 citrate and labelled
leukocyte uptake are different. After intravenous injection,
gallium-67 binds to plasma proteins, particularly transfer-
rin, but has an affinity for lactoferrin released from de-
granulated neutrophils in inflamed tissues. There is also
non-specific tissue binding due to the breakdown of the
integrity of inflamed tissue capillaries as well as binding
to siderophores, which are low molecular weight products
of bacteria.5 Imaging is performed at 48–72 h because of
prominent blood pool activity in the first 24 h after injec-
tion. With both gallium-67 and labelled leukocyte imaging,
single photon emission computed tomography (SPECT)
may lead to increased detection and accuracy over stan-
dard planar imaging. Gallium-67 citrate scintigraphy has
a high sensitivity (90%) for detecting infection. Its use is
particularly in chronic infections. However, there is a rela-
tively low specificity because of its widespread physiolog-
ical distribution and its uptake by a wide range of other
inflammatory conditions and tumours.6
The uptake of labelled cells depends on intact chemo-
taxis, the number and type of cells labelled and the
principal cellular component of that particular inflamma-
tory response. The labelled leukocytes are predominantly
neutrophils, and hence are ideal markers in identifying
neutrophil-mediated inflammatory processes.1 Imaging
is performed approximately 3 h after the labelling of
autologous white cells, enabling results to be available on
the same day.
The values for sensitivity, specificity and accuracy of
indium-111-labelled leukocyte scintigraphy for detecting
postoperative cardiothoracic infection (e.g. sternal) is 80,
97 and 95%, respectively,7 while for detecting vascular
graft infections, they are 87, 90 and 89%.8 Using indium-
111 or technetium-99 m-HMPAO-labelled white blood cell
scintigraphy to detect endocarditis, the sensitivity is 67%
and specificity is 86%.9 These values compare reasonably
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Heart Lung and Circulation
2004;13:10–12
with echocardiography. Although the latter technique still
remains the primary tool of investigation, the ability of ra-
dionuclide imaging to identify cardiac infection at an early
stage makes it an important alternative when other imag-
ing modalities fail.
Labelled leukocyte scintigraphy has identified both
prosthetic and native endocarditis with myocardial ab-
scess formation earlier than other imaging modalities.10
Early postoperative infection of an implantable cardio-
verter-defibrillator has also been detected by indium-111-
leukocyte scan.11
In this issue of the journal, Chua and Rees6 have re-
ported a rare case of cardiac mycotic aneurysm detected
early by gallium-67 citrate scintigraphy. In their case, ini-
tial transoesophageal echocardiography and CT scan did
not demonstrate an infective focus. The gallium-67 scan
was ordered in the evaluation of an aortic graft and, as is
not infrequently the case, an unexpected focus was found
at the aortic root. Subsequent coronary angiography and
then thoracotomy demonstrated a right sinus of Valsalva
mycotic aneurysm. This interesting case not only demon-
strates the utility of this technique in evaluating the heart
when other technologies fail, but illustrates the impor-
tance of looking in remote areas to detect unexpected foci
of infection.
Gallium-67 scintigraphy is also an effective method for
detecting the infective complications of cardiac surgery
or prosthetic valve surgery. Cases of infective endocardi-
tis and aortic ring abscess after replacement of an aortic
valve have been detected by gallium-67 SPECT scan where
transoesophageal and CT scan have been negative.12,13 For
pericarditis, the gallium-67 scan can be used to assess, if
required, the extent of inflammation and a possible re-
sponse to treatment.6,14
One case entailed detection of infantile endocarditis in
a 3-month-old male who was injected with gallium-67 cit-
rate to assess a suspected knee infection. The unexpected
pathology was identified prior to the appearance of clini-
cal signs; a subsequent echocardiogram confirmed that a
mitral valve vegetation was present.15
A recent development is immunoscintigraphy with
technetium-99 m-labelled intact antibodies and antigran-
ulocyte monoclonal antibody Fab’ fragments (LeukoScan).
These agents can be useful in detecting cardiac infection.
The sensitivity, specificity, positive and negative predictive
values of immunoscintigraphy with technetium-99 m-
labelled intact antibodies (BW250/183) for detection of
prosthetic valve endocarditis are 79, 82, 79 and 82%,
respectively.16 With LeukoScan these values are 66, 79, 26
and 87%.17 Using immunoscintigraphy with LeukoScan
in combination with echocardiography can improve the
sensitivity further.18
Positron emission tomography is another novel ap-
proach and has a suggested role in evaluating infections
using F-18-FDG; its cardiac role may be limited by normal
uptake in the myocardium.
Postoperative infective endocarditis and its complica-
tions may lead to serious clinical consequences. The cur-
rent incidence of prosthetic valve endocarditis is 3.7%.19
The overall mortality is 61.4% in patients with valve ring
Zhou and Better 11
Radionuclide imaging for the detection of cardiac infection
EDITORIAL
abscess managed by antibiotic therapy alone, but 39.5% if
treated with valve replacement.20 The early diagnosis of
cardiac infection is necessary for appropriate treatment
and reduction in mortality rate, and may be difficult due
to shadowing on transoesophageal echocardiography.
However, there is no definitive, reliable, non-invasive
imaging modality for early detection of pericardial and
intra-cardiac inflammatory processes. Traditional diagno-
sis depends on a patient’s history, including symptoms,
the physical examination, blood cultures, chest X-ray
and echocardiography. CT and MRI may play a role, but
early diagnosis is still difficult. Radionuclide imaging has
demonstrated moderately high sensitivity for detecting
cardiac infection. It can provide unique value in early
diagnosis, guide effective treatment, and even possibly
reduce complications and mortality rate.
In conclusion, radionuclide imaging is a powerful non-
invasive tool for evaluation of cardiac infection. It is not a
first line investigation, but, as is seen in Chua’s case study,6
it should be strongly considered when anatomical imag-
ing such as echocardiography is unrewarding but clinical
suspicion remains high.
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 12 Zhou and Better
Radionuclide imaging for the detection of cardiac infection
EDITORIAL
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