Approach to cardiac imaging in patients with suspected left-sided native valve infective endocarditis and TTE demonstrating vegetation

This algorithm summarizes our suggested initial approach to cardiac imaging in patients with suspected left-sided native valve IE. The diagnostic approaches to prosthetic valve IE and to endocarditis associated with cardiac implantable electronic devices are discussed separately (refer to UpToDate topics on prosthetic valve endocarditis and cardiac implantable electronic device infections).

CT: computed tomography; IE: infective endocarditis; TEE: transesophageal echocardiogram; TTE: transthoracic echocardiogram.

* 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).

¶ 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.

Δ 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).

References:

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.
Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 143:e35.
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.

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Approach to cardiac imaging in patients with suspected left-sided native valve infective endocarditis and TTE demonstrating vegetation