Diagnostic imaging in infective endocarditis: a contemporary perspective

ABSTRACT

Introduction

Infective endocarditis (IE) remains a diagnostic challenge. Prompt diagnosis is essential for accurate risk stratification and appropriate therapeutic decisions and surgical management. In recent years, the use of multimodal imaging has had a transformative effect on the diagnostic approach of IE in selected patients.

Areas covered

This review assesses published literature on different imaging modalities for the diagnosis of IE published between 1 January 2009 and 1 February 2020. We illustrate the diagnostic approach to IE with three clinical cases.

Expert opinion

Novel approaches to imaging for cardiac and extracardiac complications improve and individualize diagnosis, management, and prognosis in patients with suspected IE. The use of multimodal imaging should be guided by a multidisciplinary group of medical providers that includes infectious disease specialists, radiologists, cardiologists, and cardiothoracic surgeons.

KEYWORDS:

• Endocarditis
• imaging
• native valve
• prosthetic valve
• intracardiac device

Article highlights

• Despite the availability of additional imaging tools, echocardiography remains the first-line imaging modality in the diagnosis of IE and associated cardiac complications.

• Echocardiography may be insufficient for IE diagnosis in up to one-third of the cases. The sensitivity is lower in patients with a prosthetic valve, annuloplasty ring, or an electronic cardiac device.

• Cardiac CT is an alternative to echocardiography in adults who have contraindications for TEE but in whom there is concern for prosthetic valve IE or high clinical suspicion of native valve IE despite negative TTE or concern for paravalvular extension of infection. Patients with an irregular heart rhythm or tachycardia are poor candidates for a cardiac CT.

• In patients with neurological symptoms, a head CT should be the initial diagnostic imaging to evaluate for territorial infarction or hemorrhage before valve surgery.

• Routine brain MRI screening is not recommended in IE patients without central neurologic signs/symptoms.

• PET/CT and leukocyte scintigraphy are useful adjunctive imaging modalities in patients with suspected prosthetic valve IE or a CIED related infection.

Declaration of interest

M.R. Sohail reports other relationships not directly relevant to the subject matter discussed in this manuscript, including funds from TYRX Inc. and Medtronic for prior research unrelated to this study administered according to a sponsored research agreement between Mayo Clinic and study sponsor that prospectively defined the scope of the research effort and corresponding budget; and honoraria/consulting fees from Medtronic Inc. and Aziyo Biologics, Inc. L Baddour reports non-relevant financial relations that include: UpToDate, Inc. (Royalty payments); Boston Scientific (Consultant activities). The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.