In reply: Infective endocarditis: Don’t forget the ICE
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* Nkemdilim Mgbojikwe
* Steven R. Jones
* Thorsten M. Leucker
* Daniel J. Brotman

**In reply**: The letter from Drs. Araj and Luna regarding the utilization of intracardiac echocardiography (ICE) raises several interesting points. Indeed, for patients with infective endocarditis with inconclusive findings on transthoracic echocardiography (TTE) and contraindications to use of contrast-mediated studies or transesophageal echocardiography (TEE), ICE does present another potentially useful diagnostic modality. However, it is an invasive procedure, and as such, the clinical team would need to weigh the risk of complications. Further, while the authors suggest that the cost is comparable to that of TEE, the likely higher cost relative to positron emission tomography (PET) and other advanced imaging methodologies, as well as availability of institutional expertise, experience, and availability, should also be considered.

ICE, similar to TTE and TEE, relies upon the finding of an anatomic abnormality, in this case, the demonstration of a vegetation, for the diagnosis of infectious endocarditis. 18FDG-PET does not rely on anatomic identification of vegetations but is a functional examination detecting inflammation, which can be helpful in detecting microscopic vegetations not identifiable by echocardiography.

Since the absence of an anatomically detected vegetation does not exclude infectious endocarditis, PET has potentially complementary additive value to the various modalities based on demonstration of vegetation for the diagnosis of infectious endocarditis.

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