Cardiovascular Imaging in Infective Endocarditis

Abstract

Multimodality imaging plays a pivotal role in the evaluation and management of infective endocarditis (IE)—a condition with high morbidity and mortality. The diagnosis of IE is primarily based on the modified Duke criteria with echocardiography as the first-line imaging modality. Both transthoracic and transesophageal echocardiography delineate vegetation location and size, assess for paravalvular extension of infection, and have the added advantage of defining the hemodynamic effects of valvular or device infection. Native and prosthetic valve IE, infections relating to cardiac implantable electronic devices, and indwelling catheters are effectively evaluated with echocardiography. However, complementary imaging is occasionally required when there remains diagnostic uncertainty following transesophageal echocardiography. Multidetector computed tomography and nuclear imaging techniques such as positron emission tomography and white blood cell scintigraphy have been shown to reduce the rate of misdiagnosed IE particularly in the setting of prosthetic valve endocarditis, paravalvular extension of infection, and cardiac implantable electronic devices. In this review, we describe a modern approach to cardiac imaging in native and prosthetic valve endocarditis, as well as cardiac implantable electronic devices including pacing devices and left ventricular assist devices. Current guidelines addressing the role of multimodality imaging in IE are discussed. The utility of imaging in the assessment of local and distant endocarditis complications such as pericardial sequelae, myocarditis, and embolic events is also addressed.

The role of imaging in infective endocarditis

“…Additionally, TEE is more sensitive than TTE in detecting vegetation of pulmonary valve and cardiovascular implanted devices IE. TEE is also useful in detection of right sided IE, in aortic root abscess extension and in the presence of VSD 5 …”

“…IE can affect any part of the valve, and there is also the possibility of paravalvular extension, which makes accurate IE diagnosis significantly more difficult. 5 Artificial valve IE is also suspected in the occurrence of dehiscence, in the absence of vegetation or valvular abscess, when echocardiographic examination visualizes paravalvular regurgitation with oscillatory movement of the prosthetic valve.…”

Cardiac Magnetic Resonance Imaging for the Diagnosis of Infective Endocarditis in the COVID-19 Era

“…The goals of echocardiographic evaluation include assessing the anatomy of the valvular structures, identifying and characterizing the presence of vegetations, defining any resultant impairment in valvular function, assessing for paravalvular extension or abscesses, identifying involvement of prosthetic valves, examining indwelling catheters, assessing intracardiac devices such as a left ventricular assist device, and for patients with a cardiac implantable electronic device (CIED) such as a permanent pacemaker or implantable cardioverter-defibrillator (ICD), visualizing the leads if possible. 8 While transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) often serve complimentary roles, TEE as compared to TTE is a superior modality of imaging due to its enhanced spatial resolution resulting in higher sensitivity for identifying and characterizing valvular vegetations and paravalvular extension, particularly in the setting of prosthetic valves. 7 , 9 Three-dimensional (3D) TEE also allows for improved identification of valvular vegetation vs abscess, leaflet perforation, prosthetic paravalvular leak, prosthetic valve dehiscence, and vegetation size and localization.…”

“…10 However, when there remains diagnostic uncertainty following TEE, particularly in the setting of prosthetic valves, paravalvular extension, and intracardiac devices, the modern diagnostic approach involves the utilization of multimodality imaging techniques such as leukocyte scintigraphy, 18 F-fluorodeoxyglucose positron emission tomography / computed tomography ( 18 FDG PET/CT), multidetector computed tomography (MDCT), and cardiac magnetic resonance imaging (CMR). 8 , 11 Recent advancements in radiotracers, multidetector scanners, iterative reconstruction algorithms, magnet field strength, and artificial intelligence models have allowed multimodality imaging to help improve diagnostic accuracy and inform management decisions. 8 …”

“… 8 , 11 Recent advancements in radiotracers, multidetector scanners, iterative reconstruction algorithms, magnet field strength, and artificial intelligence models have allowed multimodality imaging to help improve diagnostic accuracy and inform management decisions. 8 …”