Role of echocardiography in infective endocarditis
- Nelson B Schiller, MD, FACC, FRCP, FASE
Nelson B Schiller, MD, FACC, FRCP, FASE
- 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
- Xiushui Ren, MD
Xiushui Ren, MD
- Associate Research Director, Cardiology Fellowship
- California Pacific Medical Center
- 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 any surface, including valve leaflets, congenital defects, the walls or chordae of the chambers, prosthetic 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 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".)
COMPARING TTE AND TEE
Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) have complimentary roles in the diagnosis and evaluation of endocarditis. Performing an initial TTE is usually recommended, especially in individuals without a prior TTE. Many cardiologists recommend first-line TEE when a TTE is not going to be diagnostic, such as for a patient with one or more prosthetic heart valves or prior technically difficult quality TTE. The decision on when to use TEE is individualized, taking into account clinical risk factors, patient examination findings, laboratory data, and diagnostic quality of the TTE.
The transmission of ultrasound between the transducer and the heart is impeded by obesity, hyperinflated lungs during mechanical ventilation, narrow interspaces, valve/annular calcification, and valve prostheses. All of these factors may obscure the visualization of vegetations. TEE is less susceptible to these constraints and usually provides excellent image quality.
Strict TTE criteria, where a TEE is unlikely to yield additional diagnostic information among individuals with bacteremia, have been proposed after an analysis of 790 individuals with both TTE and TEE in suspected endocarditis. When the TTE had moderate or better ultrasound quality, normal anatomy, no valvular stenosis or sclerosis, less than mild valvular vegetation, no significant pericardial effusion, no catheter or pacemaker leads, and no evidence of vegetation, the negative predictive value of TTE was 97 percent .
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- COMPARING TTE AND TEE
- WHO NEEDS A TTE?
- WHO NEEDS A TEE?
- DIFFERENTIAL DIAGNOSIS OF CARDIAC MASSES IDENTIFIED BY ECHOCARDIOGRAM
- DIAGNOSIS OF INFECTIVE ENDOCARDITIS
- PROGNOSTIC MARKERS
- RECOGNITION OF INTRACARDIAC COMPLICATIONS OF ENDOCARDITIS
- Valvular regurgitation
- Perivalvular abscess or fistula
- Other complications
- MANAGEMENT IMPACT OF ECHOCARDIOGRAPHIC FINDINGS
- FOLLOW-UP ECHOCARDIOGRAMS
- PROSTHETIC VALVE ENDOCARDITIS
- SUMMARY AND RECOMMENDATIONS