The role of multimodality imaging in the evaluation of IE.
| Imaging modality | Indications | Advantages | Limitations | Special considerations | Key role in IE evaluation |
|---|---|---|---|---|---|
| Transthoracic echocardiography (TTE) | Initial imaging for suspected endocarditis; screening tool | Widely available, non-invasive, bedside use, good for large vegetations or valve dysfunction | Limited sensitivity (especially in prosthetic valves or obese patients), operator dependent | Should be done in all suspected cases; may need to be followed by transesophageal echocardiography (TEE) | Initial assessment of valve structure, function, and large vegetations |
| TEE | High-risk patients, prosthetic valves, inconclusive TTE, suspected complications | High resolution; superior for detecting abscess, perforation, prosthetic valve endocarditis | Semi-invasive, sedation required, less accessible | Essential in suspected prosthetic valve endocarditis or device-related infections | Gold standard for valve and periannular complication assessment |
| Cardiac CT (CTA/CT angiography) | Assessment of periannular complications, prosthetic valves, coronary evaluation pre-surgery | High spatial resolution, visualizes abscesses, pseudoaneurysms, and fistulas | Radiation, contrast use, less sensitive for vegetations | Valuable in surgical planning and in prosthetic valve endocarditis | Complement to TEE for structural complications, especially in prosthetic valves |
| 18F-FDG-PET/CT (nuclear imaging) | Prosthetic valve endocarditis, device infections, fever of unknown origin with suspicion for IE | Functional imaging, detects inflammatory activity, whole-body evaluation | False positives (post-op), poor spatial resolution, not ideal for native valves | Requires strict preparation; best > 3 months post-surgery to reduce false positives | Detection of prosthetic valve and device-related infections; extracardiac emboli |
| Radiolabeled leukocyte scan | Suspected IE when other imaging is inconclusive, prosthetic material infections | Specific for active infection, especially useful when 18F-FDG-PET/CT is equivocal | Limited availability, time-consuming, less anatomical detail | May complement PET/CT in complex or inconclusive cases | Alternative nuclear method for infection localization |
IE: infective endocarditis; CT: computed tomography; FDG: fluorodeoxyglucose; PET: positron emission tomography.
TC: Investigation, Writing—original draft, Writing—review & editing. JER: Investigation, Writing—review & editing, Visualization. SLPV: Writing—review & editing, Validation. TKMW: Conceptualization, Supervision, Writing—review & editing, Project administration. All authors read and approved the final manuscript.
The authors declare that they have no conflicts of interest.
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