Echocardiography in Infective Endocarditis: State of the Art

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Purpose of Review

In this review, we examine the central role of echocardiography in the diagnosis, prognosis, and management of infective endocarditis (IE).

Recent Findings

2D transthoracic echocardiography (TTE) and transesophageal echocardiography TEE have complementary roles and are unequivocally the mainstay of diagnostic imaging in IE. The advent of 3D and multiplanar imaging have greatly enhanced the ability of the imager to evaluate cardiac structure and function. Technologic advances in 3D imaging allow for the reconstruction of realistic anatomic images that in turn have positively impacted IE-related surgical planning and intervention. CT and metabolic imaging appear to be emerging as promising ancillary diagnostic tools that could be deployed in select scenarios to circumvent some of the limitations of echocardiography.


Our review summarizes the indispensable and central role of various echocardiographic modalities in the management of infective endocarditis. The complementary role of 2D TTE and TEE are discussed and areas where 3D TEE offers incremental value highlighted. An algorithm summarizing a contemporary approach to the workup of endocarditis is provided and major societal guidelines for timing of surgery are reviewed.

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    Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

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    Correspondence to Luis Afonso.

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    Luis Afonso, Anupama Kottam, Vivek Reddy, and Anirudh Penumetcha declare that they have no conflict of interest.

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    Electronic Supplementary Material

    Marantic endocarditis. Transesophageal echocardiogram at 120 degrees mid esophageal left ventricular outflow tract view showing a globular lesion attached to the aortic valve non-coronary cusp. (AVI 781 kb)

    Fig. S1

    Mural endocarditis. Transesophageal echocardiogram bicaval view at 100 degrees showing a large vegetation attached to the right atrial endocardium at the junction of the free wall and right atrial appendage. No valvular vegetations were seen in this patient. Blood culture grew MRSA bacteremia. RAA- right atrial appendage. (JPEG 47 kb)

    Fig. S2

    Mural Endocarditis. Transesophageal echocardiogram at mid esophageal short axis view showing a thin layer of mural endocarditis along the left atrial wall extending to the interatrial septum. Blood culture grew MRSA bacteremia. (JPEG 41 kb)

    Fig. S3

    Mitral valve regurgitation. a. Transesophageal echocardiogram in 0 degrees, 4-chamber view at mid esophageal level showing destructive mitral endocarditis. Note flail anterior mitral leaflet and significant malcoaptation. b. Color Doppler shows severe eccentric mitral regurgitation. LA, Left atrium; LV, Left ventricle (JPEG 49 kb)

    Fig. S4

    Pseudoaneurysm. a. Transesophageal echocardiogram at 170 degrees mid esophageal level showing a large pseudoaneurysm of the mitral-aortic intervalvular fibrosa with arrow present. Echogenicity within the pseudoaneurysm suggests an abscess. b. Communication of pseudoaneurysm with the left ventricular cavity is noted on color Doppler. Also note collapse of aneurysm during diastole and expansion during systole in Fig. A. BPAV, Bioprosthetic aortic valve; LA Left atrium; LV Left ventricle; MAIF Mitral-aortic interannular fibrosa. Blood culture grew MRSA (JPEG 101 kb)

    Fig. S5

    Marantic endocarditis. a. Transesophageal echocardiogram at 120 degrees mid esophageal left ventricular outflow tract view showing a globular lesion attached to the aortic valve non-coronary cusp b. Similar lesion is found attached to the mitral leaflet tip at 0 degrees with arrow present. AV, Aortic valve; LA, Left atrium; LV, Left ventricle. (JPEG 60 kb)

    Fig. S6

    Marantic endocarditis. Transthoracic parasternal long axis view showing an echogenic mass attached to the aortic valve. Histopathology suggestive of non-bacterial endocarditis/ marantic endocarditis. LVOT Left ventricular outflow tract. (JPEG 20 kb)

    Video 9

    Mitral valve perforation. Transesophageal echocardiogram mid esophageal 4 chamber view at 0 degrees showing a large globular vegetation of the posterior mitral leaflet. Color Doppler in systole demonstrates a regurgitant jet through the posterior leaflet suggestive of perforation. (AVI 792 kb)

    Video 10

    Marantic endocarditis video. Transthoracic parasternal long axis view in Live 3D showing an echogenic mass attached to the aortic valve. Histopathology confirmed non-bacterial endocarditis/ marantic endocarditis. (AVI 260 kb)

    Video 1

    Prosthetic heart valve endocarditis. Transesophageal echocardiogram, mid esophageal view with biplane imaging showing vegetations of the bioprosthetic mitral valve. Dehiscience of the prosthetic valve with excessive mobility or “rocking” of prosthesis is noted in the orthogonal plane. (AVI 475 kb)

    Video 2

    Lead endocarditis. Transesophageal echocardiogram; Real time 3D off -axis bicaval view showing multiple mobile vegetations attached to the right atrial portion of the right ventricular lead. Right atrial lead was free of vegetations. Blood culture was positive for vancomycin resistant enterococci (VRE). (AVI 246 kb)

    Video 3

    Mural endocarditis video. Tranthoracic Real time 3D image of a massive pedunculated vegetation attached to the superior right atrial wall. The lesion prolapses through the tricuspid valve in diastole. Blood cultures grew MRSA. Complete resolution of the vegetation occurred after a course of antibiotics. (AVI 468 kb)

    Video 4

    Tricuspid valve endocarditis: Tranthoracic parasternal short axis view at the level of aortic valve showing small vegetation attached to the septal tricuspid leaflet. An echolucent area within the septal tricuspid leaflet suggests an area of perforation with resultant severe tricuspid regurgitation. Blood culture grew MRSA. (AVI 1080 kb)

    Video 5

    Prosthetic valve endocarditis video. Transesophageal echocardiogram at mid esophageal level showing biplane imaging of transcatheter bioprothetic aortic valve (CoreValve). Long axis plane demonstrates a mobile vegetation attached to the prosthetic leaflet. Blood culture grew Vancomycin resistant enterococci. (AVI 1126 kb)

    Video 6

    Endocarditis of ASD closure device. Transesophageal echocardiogram in bicaval view. Biplane imaging shows an ASD occluder device. Contrast imaging outlines a hypoechoic, gelatinous phlegmon (abscess) attached to the left atrial aspect of the device. Blood culture grew Morganella morganii. (AVI 931 kb)

    Video 7

    Coronary sinus endocarditis video. Transesophageal echocardiogram at 180 degrees lower esophageal view. Note a long vegetation seated deep in the coronary sinus. (AVI 1115 kb)

    Video 8

    Aortic valve perforation video. Transesophageal echocardiogram mid esophageal left ventricular outflow tract view at 130 degrees showing aortic valve vegetations involving the right and non-coronary cusps. A small area of perforation is noted in the non-coronary cusp. Two distinct jets of aortic regurgitation through both the commissure and the perforation are noted. Blood culture grew Enterococcus fecalis. (AVI 996 kb)

    Video 11

    Marantic endocarditis. Transesophageal echocardiogram at 120 degrees mid esophageal left ventricular outflow tract view showing a globular lesion attached to the aortic valve non-coronary cusp. (AVI 781 kb)

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    Afonso, L., Kottam, A., Reddy, V. et al. Echocardiography in Infective Endocarditis: State of the Art. Curr Cardiol Rep 19, 127 (2017) doi:10.1007/s11886-017-0928-9

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    • Infective endocarditis
    • 3D TEE
    • 2D TEE
    • 2D TTE