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Arockiam, A.D.; Agrawal, A.; El Dahdah, J.; Honnekeri, B.; Kafil, T.S.; Halablab, S.; Griffin, B.P.; Wang, T.K.M. Echocardiography of Infective Endocarditis. Encyclopedia. Available online: https://encyclopedia.pub/entry/41826 (accessed on 18 December 2025).
Arockiam AD, Agrawal A, El Dahdah J, Honnekeri B, Kafil TS, Halablab S, et al. Echocardiography of Infective Endocarditis. Encyclopedia. Available at: https://encyclopedia.pub/entry/41826. Accessed December 18, 2025.
Arockiam, Aro Daniela, Ankit Agrawal, Joseph El Dahdah, Bianca Honnekeri, Tahir S. Kafil, Saleem Halablab, Brian P. Griffin, Tom Kai Ming Wang. "Echocardiography of Infective Endocarditis" Encyclopedia, https://encyclopedia.pub/entry/41826 (accessed December 18, 2025).
Arockiam, A.D., Agrawal, A., El Dahdah, J., Honnekeri, B., Kafil, T.S., Halablab, S., Griffin, B.P., & Wang, T.K.M. (2023, March 02). Echocardiography of Infective Endocarditis. In Encyclopedia. https://encyclopedia.pub/entry/41826
Arockiam, Aro Daniela, et al. "Echocardiography of Infective Endocarditis." Encyclopedia. Web. 02 March, 2023.
Echocardiography of Infective Endocarditis
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This entry is adapted from the peer-reviewed paper 10.3390/life13030639

Infective endocarditis (IE) refers to an infection of the endocardial surface structures of the heart. It is a complex heterogeneous condition often with systemic complications and carries a high rate of mortality and morbidities.

infective endocarditis multi-modality imaging echocardiography

1. Introduction

Infective endocarditis (IE) refers to an infection of the endocardial surface structures of the heart [1][2]. It is a complex heterogeneous condition often with systemic complications and carries a high rate of mortality and morbidities. The diagnosis of IE is traditionally based on the modified Duke criteria, but remains challenging in many clinical scenarios, and delayed diagnosis may lead to irreversible harm to patients [3]. Transthoracic echocardiography (TTE) is the first-line imaging modality for assessing IE, and transesophageal echocardiography (TEE) is required in the vast majority. Computed tomography (CT), nuclear imaging such as 18F-fluorodeoxyglucose positron emission tomography/CT (18F-FDG-PET/CT) and cardiac magnetic resonance imaging (CMR) are increasingly utilized as complimentary cardiovascular imaging techniques for identifying IE and its complications, with several niche indications. Together, multi-modality cardiac imaging plays a critical role in the evaluation and treatment guidance of IE towards medical and surgical therapies.

2. Echocardiography

2.1. Transthoracic Echocardiography

Echocardiography is the cornerstone of imaging modalities used for IE assessment [4]. The modified Duke criteria, which indicate whether definitive infection or probable infection is present according to major and minor criteria, have major echocardiographic criteria for IE diagnosis that include vegetations, abscesses, new valvular regurgitation, and prosthesis dehiscence, while other supporting features include valve perforation or aneurysm [1]. TTE is the first-line imaging test for IE and should be promptly performed as soon as IE is suspected [1][5][6][7]. A complete examination should be performed, involving all standard parasternal, apical, subcostal, and suprasternal views, and employing two-dimensional, Doppler, and three-dimensional techniques with careful interrogation on all four heart valves, including prosthetic heart valves and cardiac devices, as well as the aorta for signs of IE [8]. TTE can also assess the cardiac chamber’s size and function, as well as evaluating for congenital heart disease, pericardial conditions, adjacent vascular structures, and estimating pulmonary pressures. All echocardiography techniques excel with high temporal resolution, so they are generally better at identifying mobile vegetations, especially if they are small or thin compared to other modalities. TTE has many strengths, such as it being a first-line imaging modality, but with notable limitations, such as suboptimal sensitivity due to lower spatial resolution and prosthetic valve artifacts warranting further evaluation [6][9], as indicated in Table 1.
Table 1. Strengths and limitations of multi-modality imaging for evaluating infective endocarditis.
Imaging Modality Strengths Limitations
Transthoracic echocardiography (TTE) Widely available, first-line modality, safe with no radiation exposure, portable, high temporal resolution, assesses hemodynamics, valve function, endocarditis features, and chamber function. Operator and patient dependent on imaging windows, creates artifacts, lower sensitivity than more advanced modalities in identifying most endocarditis features including small vegetations, periannular complications, prosthetic valve, and device-related endocarditis.
Transesophageal echocardiography (TEE) Portable, higher sensitivity than TTE for most endocarditis features, preferred modality for vegetations, valve perforation, prosthetic valve dehiscence and paravalvular leak, identifies fistula, high spatial and temporal resolution. Invasive imaging modality, may still have artifact and lower sensitivity for some prosthetic valves and cardiac devices, avoid in contraindications such as prior gastroesophageal disease and surgery, active bleeding, patient intolerance.
Cardiac CT Short study, excellent for detection of perivalvular complications (pseudoaneurysm, abscess, and fistula) in all types of endocarditis, can also identify other endocarditis features, detect extracardiac complications, high spatial resolution, use for pre-operative workup, and assesses coronaries and major vessels. Non-portable, lower sensitivity than echocardiography for smaller vegetations, perforations, and paravalvular leaks. Inferior temporal resolution to echocardiography, radiation exposure, iodinated contrast administration (avoid in chronic renal impairment, especially when creatinine clearance below 30).
Cardiac Magnetic Resonance Can identify endocarditis complications in some scenarios, such as using its high sensitivity for cerebral lesions. Reference standard for chamber quantification and can also quantify valve disease and shunts (such as for fistula). Long study, non-portable, can cause claustrophobia, cost, non-compatible devices, lower temporal resolution than echocardiography, only for stable patients who can lie flat and follow instructions.
18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) Improved sensitivity for prosthetic valve and device-related endocarditis in some scenarios. Non-portable, low sensitivity for native valve endocarditis, no functional cine imaging, radiation exposure, special pre-test preparation, cost, false-positive results within 3 months after cardiac surgery, false-negative results in patients treated with antimicrobials.

2.2. Transesophageal Echocardiography

TEE is recommended for the vast majority of IE patients in absence of contraindications, because of its superior sensitivity and specificity to TTE from high spatial and comparable high temporal resolutions [10][11]. TEE is the best modality for evaluating vegetations, valve perforation, and prosthetic valve dehiscence, also performing well to identify pseudoaneurysm, abscesses, and fistulas (Figure 1). A comprehensive TEE examination should also be performed when assessing for IE, focusing on all four heart valves in esophageal and transgastric views [8]. In particular, contemporary three-dimensional echocardiography, including multi-planar reconstruction, is critical for the accurate depiction of the presence of IE, for its etiology and features, and usually more accurate for TEE than TTE. Clinical scenarios to use TEE include when TTE is inconclusive for IE, but there is a moderate-to-high clinical suspicion for IE; TTE is negative, but there is ongoing high clinical suspicion for IE; and TTE showing features of IE, but further evaluation for complications (such as new heart murmur, high-grade heart block, suspected abscess, embolic events, and heart failure) is required [1][2]. The last of these indications makes an argument for routinely performing TEE in all patients with IE, as TTE may miss important IE complications. TEE also plays an important role in assessing patients with prosthetic valves or intracardiac devices where TTE is less accurate and more prone to artifacts. TEE is not usually required if IE suspicion is low and TTE is negative [2]. Finally, intraoperative TEE is used for patients undergoing IE surgery to assess the extent of IE complications and the surgery needed, as well as for assessing the surgical result [1]. TTE and TEE are the cornerstones of first-line imaging modalities to assess endocarditis in all IE guidelines [1][2][12].
Life 13 00639 g002
Figure 1. Transesophageal echocardiography findings of endocarditis. (A) Aortic valve vegetation (arrow), with (B) severe aortic regurgitation (arrow) on color Doppler. (C) Aortic with echolucent space consistent with pseudoaneurysm and abscess (arrow), with (D) severe aortic regurgitation (arrow) on color Doppler. (E) Mechanical mitral valve replacement paravalvular regurgitation (arrow) associated with (F) prosthetic valve dehiscence (arrow) seen on three-dimensional assessment.

2.3. Three-Dimensional Echocardiography

Three-dimensional (3D) echocardiography is now a cornerstone technique routinely performed in both TTE and TEE, including for the assessment of IE. The three-dimensional aspect has added value for many reasons in IE assessment, including when two-dimension echocardiography findings remain uncertain, since they enable more accurate anatomical delineation, localization of pathology, and measurement via multi-planar reconstruction. Real time 3D TEE permits the assessment of the 3D volumes of cardiac anatomy in infinite planes [13]. It is able to analyze vegetation size, morphological appearance, and embolic risk, and evaluate perivalvular extensions, valve perforations, and prosthetic valve dehiscence [14][15]. Furthermore, it has a valuable role especially with TEE in the intraprocedural guidance of surgical and transcatheter interventions. Limitations of 3D include dependence on the imaging quality of the 2D data and a lower spatial and temporal resolution restricting its application for small or highly mobile vegetations [16].

2.4. Comparisons of Echocardiography Modalities

Table 2 lists sensitivities and specificities of TTE, TEE, and other cardiac imaging modalities in identifying IE features, while stress echocardiography do not have a routine role in IE assessment. Overall, the TTE and TEE sensitivities for native valve IE were 40–60% and 90–100% respectively, and for prosthetic valve IE were 17–36% and 82–96%, respectively [4][8][10]. In particular, TTE and TEE sensitivities for vegetations were 44–69% and 87–100%, respectively, and for intracardiac abscesses 28–50% vs. 80–90%, respectively [17][18][19][20]. In patients with prosthetic valve IE, TEE is of particular interest for subaortic complications detection as they are frequently underestimated with TTE [21]. Detection of abscesses or pseudoaneurysms in patients via TEE is also independently associated with increased in-hospital mortality and morbidity [22]. TEE also is the preferred modality to assess paravalvular leaks and has a higher accuracy than TTE for identifying leaflet perforation, prosthetic valve dehiscence, and fistulas. For perforation, the sensitivity and specificity of TEE was reported to be 79% and 93%, respectively [23]. Additionally, the sensitivities and specificities for abscess, fistulas, and dehiscence were 70.3% vs. 95.5%, 85.7% vs. 98.6%, and 66.6% vs. 99.2%, respectively [23]. Furthermore, echocardiography can also predict the embolic risk associated with IE lesions. Although embolic risk is multifactorial, two of the strongest predictors are the size and mobility of the vegetations [24][25][26][27][28]. Neurological emboli are seen most in large vegetations (>3 cm in greatest dimension) [29].
Table 2. Sensitivities and specificities for multi-modality imaging for evaluating various infective endocarditis findings.
  All Cases PVIE
    Sensitivity Specificity Sensitivity Specificity
Vegetations TTE 61% [30] 94% [30] 29% [31] 100% [31]
TEE [23] 96% 83% 89% 74%
CCT [23] 85% 84% 78% 94%
Perivalvular complications TTE 28% [20] 98.6% [20] 36% [31] 93% [31]
TEE 70% [23] 96% [23] 86% [31] 98% [31]
CCT [23] 88% 93%    
Perforation TTE        
TEE [23] 79% 93%    
CCT [23] 48% 93%    
Dehiscence TTE     11% [31] 100% [31]
TEE 67% [23] 99% [23] 94% [31] 97% [31]
CCT [23] 46% 97%    
All cases of endocarditis TTE 71% [32] 80% [32] 33% [31] 100% [31]
TEE 90% [22] 96% [22] 86% [31] 95% [31]
CCT     ~93% [33] 95% [33]
PET [34] 74% 88% 86% 84%
  PET-NVIE 31% 98%    
  PET-CDRIE 72% 83%    
Abbreviations: TTE: transthoracic echocardiography, TEE: transesophageal echocardiography, CCT: cardiac computed tomography, PET: 18F-fluorodeoxyglucose positron emission tomography/computed tomography, NVIE: native valve infective endocarditis, PVIE: prosthetic valve infective valve endocarditis, CDRIE: cardiac device-related infective endocarditis. There are limited data on cardiac magnetic resonance.

2.5. Repeating Echocardiography

In some clinical scenarios, repeat TTE and/or TEE should be considered. In events where both TTE and TEE assessments are negative but clinical suspicion of IE remains high, another TEE should be scheduled. This is especially true when new IE complications arise after initial echocardiographic assessment, such as embolism, heart failure, abscess, a new murmur, atrio-ventricular block, or when there is persistent evidence of sepsis and bacteremia for at least one week despite appropriate antimicrobial treatments [35]. However, no clear consensus exists on the optimal timing of repetition since it greatly depends on the patient’s pathology and risk status. The ACC/AHA 2020 guidelines recommend a TEE repetition 3–5 days after first TEE evaluation, while the ESC guidelines recommend 7–10 days wait before repetition [1][2]. Some studies suggest less of a waiting time before echocardiography repetition in higher risk patients such as those with suspected prosthetic valve IE or Staphylococcus aureus infection [28][36]. This short-term interval repetition should enhance the sensitivity of the assessment [33], although an alternative approach is pursuing other complimentary imaging modalities. Echocardiography should also be repeated at the end of an antimicrobial course to assess for the improvement and resolution of IE findings, and for routine surveillance after valve surgery.

References

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Contributors MDPI registered users' name will be linked to their SciProfiles pages. To register with us, please refer to https://encyclopedia.pub/register : Aro Daniela Arockiam , Ankit Agrawal , Joseph El Dahdah ,
Bianca Honnekeri
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Tahir S. Kafil
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Saleem Halablab
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Brian P. Griffin
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