Review

Imaging to evaluate suspected infective endocarditis

Ikram-Ul Haq, MD, Iqraa Haq, BS, Brian Griffin, MD and Bo Xu, MD, FACC, FRACP, FASE
Cleveland Clinic Journal of Medicine March 2021, 88 (3) 163-172; DOI: https://doi.org/10.3949/ccjm.88a.19142

Article Figures & Data

Figures

  • Figure 1
    Figure 1

    (A) Transesophageal echocardiography, mid-esophageal long-axis view, demonstrates a prominent aortic root abscess cavity (white arrow) posteriorly in a patient with a prosthetic aortic valve. Also note partial dehiscence of the aortic bioprosthesis (red arrow). (B) Color Doppler analysis demonstrates significant aortic regurgitation between the aortic bioprosthesis and the left ventricular outflow tract through the prominent abscess cavity.

  • Figure 2
    Figure 2

    Utility of adjuvant advanced cardiovascular imaging—multidetector cardiac computed tomography (MDCT) and 18F-fluorodeoxyglucose positron emission tomography/CT (FDG-PET/CT)—in the diagnosis of infective endocarditis. A 68-year-old woman with Staphylococcus aureus bacteremia in the setting of a bioprosthetic aortic valve developed fever and acute right lower limb pain. Initial transesophageal echocardiography (mid-esophageal long-axis view) showed no obvious vegetation associated with the bioprosthesis (A). Due to ongoing clinical suspicion for prosthetic aortic valve endocarditis, MDCT was performed (B) and, at the level of the aortic root, showed abnormal thickening with elevated Hounsfield units (mean: 76.4 units), highly suspicious for periprosthetic aortic root abscess. FDG-PET/CT (C), demonstrated abnormal increased activity at the aortic root and mitral annulus (arrows).

  • Figure 3
    Figure 3

    A proposed diagnostic algorithm for infective endocarditis.

    TEE = transesophageal echocardiography; TTE = transthoracic echocardiography

Tables

  • TABLE 1

    Imaging for endocarditis: ESC10 and AHA4 recommendationsa

    Obtain echocardiography as soon as endocarditis is suspected
    (ESC and AHA)
    For initial investigation:
    Transthoracic echocardiography (TTE) should be used (ESC)
    Both TTE and transesophageal echocardiography (TEE) should be used (AHA)
    Perform TEE:
    If TTE is not diagnostic in patients with known or suspected infective endocarditis (ESC and AHA)
    If complications are suspected (eg, new murmur, embolism, persisting fever, heart failure, abscess, atrioventricular block) (ESC and AHA)
    If intracardiac device, leads, or prosthetic valves are present (ESC and AHA)
    Repeat TEE if initial TTE is negative but clinical suspicion of infective endocarditis remains high:
    7-10 days later (ESC), or
    3-5 days later (AHA)

    • ↵a All recommendations listed are class 1 (strong).

    • AHA = American Heart Association; ESC = European Society of Cardiology

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