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Role of echocardiography in infective endocarditis

Nelson B Schiller, MD
Bryan Ristow, MD, FACC, FASE, FACP
Section Editors
Warren J Manning, MD
William H Gaasch, MD
Deputy Editor
Brian C Downey, MD, FACC


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 [1]. (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 [2]. 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".)


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) [1]. 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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Literature review current through: Sep 2016. | This topic last updated: Sep 7, 2016.
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