Role of echocardiography in infective endocarditis
- Nelson B Schiller, MD
Nelson B Schiller, MD
- Section Editor — Noninvasive Cardiac Imaging and Stress Testing
- Professor of Medicine and Anesthesia
- University of California, San Francisco
- Bryan Ristow, MD, FACC, FASE, FACP
Bryan Ristow, MD, FACC, FASE, FACP
- Associate Clinical Professor of Medicine
- University of California, San Francisco
- Section Editors
- Warren J Manning, MD
Warren J Manning, MD
- Section Editor — Noninvasive Cardiac Imaging and Stress Testing
- Professor of Medicine and Radiology
- Harvard Medical School
- William H Gaasch, MD
William H Gaasch, MD
- Section Editor — Valvular Disease
- Professor of Medicine
- University of Massachusetts Medical School
- Tufts University School of Medicine
- Senior Consultant in Cardiology
- Lahey Clinic
Infection of the endocardium, or lining layer of the heart, can occur on valve leaflets, congenital defects, the walls or chordae of the chambers, paraprosthetic tissue, or the attachment of implanted shunts, conduits, and fistulae. The clinical diagnosis of infective endocarditis (IE) is based upon a combination of features such as positive blood cultures, echocardiographic findings, and other clinical or laboratory criteria (table 1A-B) as specified in the modified Duke criteria . (See "Clinical manifestations and evaluation of adults with suspected native valve endocarditis".)
The original case definition of endocarditis required direct anatomic inspection (during autopsy or at surgery) for confirmation of diagnosis. While no noninvasive technique can definitively establish the diagnosis, echocardiography, because of its high sensitivity for detection of valvular vegetations and complications of IE, is considered mandatory in the clinical diagnosis and treatment of this disorder. The American Heart Association/American College of Cardiology (AHA/ACC) guidelines for valvular heart disease include recommendations in both native valve and prosthetic valve endocarditis and have adopted the modified Duke criteria . The 2015 AHA Scientific Statement and the 2015 European Society of Cardiology (ESC) Guidelines on IE provide further details on the role of echocardiography [3,4]. (See 'Recommendations for performing echocardiography' below.)
The use of echocardiography in IE will be reviewed here, with emphasis on the clinical issues of its application and its potential weaknesses and pitfalls. The clinical diagnostic approach to this disorder is discussed separately. (See "Clinical manifestations and evaluation of adults with suspected native valve endocarditis".)
DIAGNOSIS OF INFECTIVE ENDOCARDITIS
The modified Duke criteria for diagnosis of infective endocarditis include three echocardiographic structural findings as major criteria: presence of an oscillating intracardiac mass, presence of an abscess, or partial dehiscence of a prosthetic valve (table 1A-B) . Less common echocardiographic findings of IE include pseudoaneurysm, fistula, or valve perforation. New valvular regurgitation is a major criterion in the American Heart Association (AHA) Valvular Heart Disease Guideline and AHA Scientific Statement [2,3].
The first target of the echocardiography examination is the identification, characterization, and localization of masses consistent with valvular vegetation, the pathologic hallmark of endocarditis. This process consists of integrating circumstantial findings and epiphenomena, and, through indirect but compelling evidence, reaching a reasonable conclusion that a given set of echocardiographic observations has identified the vegetation. Once a vegetation has been identified, a series of criteria can be applied to judge prognosis.
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- DIAGNOSIS OF INFECTIVE ENDOCARDITIS
- VALVULAR VEGETATIONS
- Procedural considerations
- - Transducer frequency
- - Commercial instrument and instrument setting variation
- - Patient physical characteristics
- - Pretest expectations
- M-mode echocardiography
- Transthoracic echocardiography
- Transesophageal echocardiography
- - Indications for TEE
- - False positive results
- - False negative results
- Diagnostic criteria for vegetations
- Natural history of vegetations
- Non-infective endocarditis
- RECOMMENDATIONS FOR PERFORMING ECHOCARDIOGRAPHY
- ECHOCARDIOGRAPHIC ESTIMATION OF OUTCOME
- Transthoracic echocardiography
- - Vegetation size and embolic risk
- Echocardiographic indications for surgery
- RECOGNITION OF INTRACARDIAC COMPLICATIONS OF ENDOCARDITIS
- Valvular regurgitation
- Perivalvular abscess or fistula
- Other complications
- RIGHT-SIDED ENDOCARDITIS
- PROSTHETIC VALVE ENDOCARDITIS