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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: Nov 2016. | This topic last updated: Wed Sep 07 00:00:00 GMT+00:00 2016.
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  1. Li JS, Sexton DJ, Mick N, et al. Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis 2000; 30:633.
  2. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63:e57.
  3. Baddour LM, Wilson WR, Bayer AS, et al. Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association. Circulation 2015; 132:1435.
  4. Habib G, Lancellotti P, Antunes MJ, et al. 2015 ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J 2015; 36:3075.
  5. Flachskampf FA, Wouters PF, Edvardsen T, et al. Recommendations for transoesophageal echocardiography: EACVI update 2014. Eur Heart J Cardiovasc Imaging 2014; 15:353.
  6. Berdejo J, Shibayama K, Harada K, et al. Evaluation of vegetation size and its relationship with embolism in infective endocarditis: a real-time 3-dimensional transesophageal echocardiography study. Circ Cardiovasc Imaging 2014; 7:149.
  7. Tanis W, Teske AJ, van Herwerden LA, et al. The additional value of three-dimensional transesophageal echocardiography in complex aortic prosthetic heart valve endocarditis. Echocardiography 2015; 32:114.
  8. Anwar AM, Nosir YF, Alasnag M, Chamsi-Pasha H. Real time three-dimensional transesophageal echocardiography: a novel approach for the assessment of prosthetic heart valves. Echocardiography 2014; 31:188.
  9. Hirschfeld DS, Schiller N. Localization of aortic valve vegetations by echocardiography. Circulation 1976; 53:280.
  10. Showler A, Burry L, Bai AD, et al. Use of Transthoracic Echocardiography in the Management of Low-Risk Staphylococcus aureus Bacteremia: Results From a Retrospective Multicenter Cohort Study. JACC Cardiovasc Imaging 2015; 8:924.
  11. Palraj BR, Baddour LM, Hess EP, et al. Predicting Risk of Endocarditis Using a Clinical Tool (PREDICT): Scoring System to Guide Use of Echocardiography in the Management of Staphylococcus aureus Bacteremia. Clin Infect Dis 2015; 61:18.
  12. Sivak JA, Vora AN, Navar AM, et al. An Approach to Improve the Negative Predictive Value and Clinical Utility of Transthoracic Echocardiography in Suspected Native Valve Infective Endocarditis. J Am Soc Echocardiogr 2016; 29:315.
  13. Shively BK, Gurule FT, Roldan CA, et al. Diagnostic value of transesophageal compared with transthoracic echocardiography in infective endocarditis. J Am Coll Cardiol 1991; 18:391.
  14. Pedersen WR, Walker M, Olson JD, et al. Value of transesophageal echocardiography as an adjunct to transthoracic echocardiography in evaluation of native and prosthetic valve endocarditis. Chest 1991; 100:351.
  15. Sochowski RA, Chan KL. Implication of negative results on a monoplane transesophageal echocardiographic study in patients with suspected infective endocarditis. J Am Coll Cardiol 1993; 21:216.
  16. Shapiro SM, Young E, De Guzman S, et al. Transesophageal echocardiography in diagnosis of infective endocarditis. Chest 1994; 105:377.
  17. Birmingham GD, Rahko PS, Ballantyne F 3rd. Improved detection of infective endocarditis with transesophageal echocardiography. Am Heart J 1992; 123:774.
  18. Lowry RW, Zoghbi WA, Baker WB, et al. Clinical impact of transesophageal echocardiography in the diagnosis and management of infective endocarditis. Am J Cardiol 1994; 73:1089.
  19. Sanfilippo AJ, Picard MH, Newell JB, et al. Echocardiographic assessment of patients with infectious endocarditis: prediction of risk for complications. J Am Coll Cardiol 1991; 18:1191.
  20. Sampedro MF, Patel R. Infections associated with long-term prosthetic devices. Infect Dis Clin North Am 2007; 21:785.
  21. Rohmann S, Erbel R, Darius H, et al. Prediction of rapid versus prolonged healing of infective endocarditis by monitoring vegetation size. J Am Soc Echocardiogr 1991; 4:465.
  22. Buda AJ, Macdonald IL, David TE, Kerwin AJ. Rapidly progressive vegetative endocarditis. Acta Cardiol 1982; 37:85.
  23. Kisslo J, Guadalajara JF, Stewart JA, Stack RS. Echocardiography in infective endocarditis. Herz 1983; 8:271.
  24. Tak T, Rahimtoola SH, Kumar A, et al. Value of digital image processing of two-dimensional echocardiograms in differentiating active from chronic vegetations of infective endocarditis. Circulation 1988; 78:116.
  25. Mügge A, Daniel WG, Frank G, Lichtlen PR. Echocardiography in infective endocarditis: reassessment of prognostic implications of vegetation size determined by the transthoracic and the transesophageal approach. J Am Coll Cardiol 1989; 14:631.
  26. Mügge A. Echocardiographic detection of cardiac valve vegetations and prognostic implications. Infect Dis Clin North Am 1993; 7:877.
  27. Heinle S, Wilderman N, Harrison JK, et al. Value of transthoracic echocardiography in predicting embolic events in active infective endocarditis. Duke Endocarditis Service. Am J Cardiol 1994; 74:799.
  28. De Castro S, Magni G, Beni S, et al. Role of transthoracic and transesophageal echocardiography in predicting embolic events in patients with active infective endocarditis involving native cardiac valves. Am J Cardiol 1997; 80:1030.
  29. Vilacosta I, Graupner C, San Román JA, et al. Risk of embolization after institution of antibiotic therapy for infective endocarditis. J Am Coll Cardiol 2002; 39:1489.
  30. Di Salvo G, Habib G, Pergola V, et al. Echocardiography predicts embolic events in infective endocarditis. J Am Coll Cardiol 2001; 37:1069.
  31. Steckelberg JM, Murphy JG, Ballard D, et al. Emboli in infective endocarditis: the prognostic value of echocardiography. Ann Intern Med 1991; 114:635.
  32. Dickerman SA, Abrutyn E, Barsic B, et al. The relationship between the initiation of antimicrobial therapy and the incidence of stroke in infective endocarditis: an analysis from the ICE Prospective Cohort Study (ICE-PCS). Am Heart J 2007; 154:1086.
  33. Akins EW, Slone RM, Wiechmann BN, et al. Perivalvular pseudoaneurysm complicating bacterial endocarditis: MR detection in five cases. AJR Am J Roentgenol 1991; 156:1155.
  34. Tingleff J, Egeblad H, Gøtzsche CO, et al. Perivalvular cavities in endocarditis: abscesses versus pseudoaneurysms? A transesophageal Doppler echocardiographic study in 118 patients with endocarditis. Am Heart J 1995; 130:93.
  35. Daniel WG, Mügge A, Martin RP, et al. Improvement in the diagnosis of abscesses associated with endocarditis by transesophageal echocardiography. N Engl J Med 1991; 324:795.
  36. Leung DY, Cranney GB, Hopkins AP, Walsh WF. Role of transoesophageal echocardiography in the diagnosis and management of aortic root abscess. Br Heart J 1994; 72:175.
  37. Karalis DG, Bansal RC, Hauck AJ, et al. Transesophageal echocardiographic recognition of subaortic complications in aortic valve endocarditis. Clinical and surgical implications. Circulation 1992; 86:353.
  38. Zabalgoitia M, Garcia M. Pitfalls in the echo-Doppler diagnosis of prosthetic valve disorders. Echocardiography 1993; 10:203.
  39. Hill EE, Herijgers P, Claus P, et al. Abscess in infective endocarditis: the value of transesophageal echocardiography and outcome: a 5-year study. Am Heart J 2007; 154:923.
  40. Anguera I, Miro JM, Cabell CH, et al. Clinical characteristics and outcome of aortic endocarditis with periannular abscess in the International Collaboration on Endocarditis Merged Database. Am J Cardiol 2005; 96:976.
  41. Piper C, Hetzer R, Körfer R, et al. The importance of secondary mitral valve involvement in primary aortic valve endocarditis; the mitral kissing vegetation. Eur Heart J 2002; 23:79.
  42. De Castro S, Cartoni D, d'Amati G, et al. Diagnostic accuracy of transthoracic and multiplane transesophageal echocardiography for valvular perforation in acute infective endocarditis: correlation with anatomic findings. Clin Infect Dis 2000; 30:825.
  43. Hecht SR, Berger M. Right-sided endocarditis in intravenous drug users. Prognostic features in 102 episodes. Ann Intern Med 1992; 117:560.
  44. Winslow T, Foster E, Adams JR, Schiller NB. Pulmonary valve endocarditis: improved diagnosis with biplane transesophageal echocardiography. J Am Soc Echocardiogr 1992; 5:206.
  45. Hutchison SJ, Rosin BL, Curry S, Chandraratna PA. Transesophageal Echocardiographic Assessment of Lesions of the Right Ventricular Outflow Tract and Pulmonic Valve. Echocardiography 1996; 13:21.
  46. San Román JA, Vilacosta I, Zamorano JL, et al. Transesophageal echocardiography in right-sided endocarditis. J Am Coll Cardiol 1993; 21:1226.
  47. Ronderos RE, Portis M, Stoermann W, Sarmiento C. Are all echocardiographic findings equally predictive for diagnosis in prosthetic endocarditis? J Am Soc Echocardiogr 2004; 17:664.
  48. Daniel WG, Mügge A, Grote J, et al. Comparison of transthoracic and transesophageal echocardiography for detection of abnormalities of prosthetic and bioprosthetic valves in the mitral and aortic positions. Am J Cardiol 1993; 71:210.
  49. Alton ME, Pasierski TJ, Orsinelli DA, et al. Comparison of transthoracic and transesophageal echocardiography in evaluation of 47 Starr-Edwards prosthetic valves. J Am Coll Cardiol 1992; 20:1503.
  50. Roe MT, Abramson MA, Li J, et al. Clinical information determines the impact of transesophageal echocardiography on the diagnosis of infective endocarditis by the duke criteria. Am Heart J 2000; 139:945.
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