Approach to cardiac imaging in patients with suspected left-sided native valve infective endocarditis and negative or indeterminate TTE

TTE: transthoracic echocardiogram; IE: infective endocarditis; TEE: transesophageal echocardiogram; CT: computed tomography; AV: atrioventricular; FDG PET/CT: fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography.

* Criteria for suspected left-sided native valve IE are discussed in the text (refer to the UpToDate topic on clinical manifestations and diagnosis of left-sided native valve IE).

¶ Nondiagnostic means that the study did not adequately assess the left heart valves. Indeterminate means that the study revealed findings that were suggestive but not diagnostic for vegetation or abscess.

Δ If TEE is nondiagnostic, cardiac CT may facilitate evaluation for paravalvular abscess. In addition, cardiac CT may be useful alternative modality for patients unable to undergo TEE. Decisions regarding advanced cardiac imaging should be made in consultation with infectious disease, cardiology, and/or cardiac surgery specialists.

◊ Anatomic indications for surgery include (1) IE-associated valve dysfunction causing heart failure and (2) paravalvular extension of infection with development of abscess, fistula, and/or heart block (refer to UpToDate topic on surgery for left-sided native valve IE for further discussion).