Echocardiography plays a key role in the diagnosis and management of infective endocarditis. Transthoracic echocardiography is the initial test used but has only 40-63% sensitivity for detecting vegetations, which are a hallmark of infective endocarditis. Transesophageal echocardiography is significantly more sensitive at 90-99% and is recommended if transthoracic is negative but strong suspicion of infective endocarditis remains. Echocardiography can identify vegetations and characterize them based on location, size, shape, echogenicity and mobility. It also detects complications like abscesses, fistulas and new valvular regurgitation. Serial echocardiograms

1. Echocardiography
& EndocarditisDr. Md. Fakhrul Islam Khaled
Assistant Professor
Department of Cardiology, BSMMU

2. Overview
 Background
 Diagnosis
 ACC/AHA indications for Echo
 TTE versus TEE
 Diagnostic Echo criteria
 Echocardiographic estimation of outcome
 Intracardiac complications of endocarditis

3. Background
 Infection of endocardium
 valve leaflets, congenital defects, chamber walls
or chordae, prosthetic valves/conduits

4. Background
 Infection of endocardium
 valve leaflets, congenital defects, chamber walls
or chordae, prosthetic valves/conduits
 Diagnosis: modified Duke criteria
 No noninvasive technique can definitively
diagnose
 Echocardiography has high sensitivity for IE and
intracardiac abscess
 Mandatory in the diagnosis and treatment of IE

5. Goals of Echo in Possible IE
 Identify, localize, and characterize masses consistent with vegetations
 Identify new valvular regurgitation
 Examine prosthetic valve stability
 Apply criteria to judge prognosis once vegetation identified

13. Diagnostic Echo criteria
Characteristics of mass likely to be a vegetation:
 Texture: gray scale and reflectance of myocardium

16. Diagnostic Echo criteria
Characteristics of mass likely to be a vegetation:
 Texture: gray scale and reflectance of myocardium
 Location: upstream side of valve in path of jet or on
prosthetic material

18. TTE vs TEE for
VEGETATIONS TTE is initial diagnostic test
 TTE can miss vegetation < 0.5cm in size
 TTE vs TEE sensitivity 40-63% vs 90-99%,
specificity 90-98% vs 91-99%
 Repeat TEE after 7-10 days in patients with strong suspicion of vegetation

20. OBJECTIVES OF ECHO FOR
VEGETATIONS
I. Detection of cardiac vegetation
II. Demonstration of local complications
III. Diagnosis of predisposing lesions
IV. Evaluation of responses to treatment
V. Proper timing of surgical intervention

21. ECHO FEATURES OF
ENDOCARDITIS
1. Detection
2. Site
3. Size
4. shape
5. Echogenecity
6. Mobility
7. Differentiation from different masses

22. 1. DETECTION
 2D – mobile, irregular,
echogenic, attached to
valve cusp or cardiac lesion
and prolapsing in one of
chambers
 M- mode : thick dense,
irregular multiple echoe
lines seen on one or more
valve leaflets

23. 2. SITE
 It depends on underlying cardiac lesion
MR – LA
AR – LVOT
VSD - RV

24. 3. SIZE
 2 - 20mm
 <2mm difficult to visualize –TEE
 Large vegetation associated with fungal /tricuspid
 Getting smaller in size – heal
- embolization
 Mitral > aortic vegetation

25. 4. SHAPE
 Fresh vegetation – irregular/ lumpy
 Old vegetation – smoothen
 Sessile / pedunculated

26. 5. ECHOGENECITY
 Fresh vegetation – isoechoic
 Old vegetation - Hyperechoic

27. 6. MOBILITY
 High – large /pedunculated vegetation
 Low – small/sessile vegetation

28. 7. DIFFERENTIATION FROM
OTHER MASSES
Difficult to differentiate from these :
 Myxomatous changes in floppy valve
 Thrombus formation in prosthetic valve
 Calcified nodules on thick Rheumatic Valve

29. MITRAL / AORTIC VALVE VEGETATION

30. TRICUSPID VALVE VEGETATON

32. DIFFERENTIATING FRESH /
HEALED VEGETATION
FRESH HEALED
SIZE LARGE SMALL
SHAPE
IRREGULAR SMOOTH
MOBILITY MOBILE IMMOBILE
ECHOGENECITY ISOECHOIC
HYPERECHOIC

33. DIFFERENTIATING MITRAL AND
AORTIC VEGETATION
MITRAL AORTIC
SIZE
LARGE
SMALL
SITE IN LA IN LVOT
MOBILE IMMOBILE

34. II. DETECTION OF LOCAL
COMPLICATION Spread of endocarditis on
– on other valve
- on other parts of valve leaflets/chordea
 HF from associated myocarditis, pericardial effusion, acute valvular
regurgitation
 Abscess formation –rupture of sinus of valsalva – L to R shunt
 Valvular regurgitation - rupture/ perforation/ prolapse/
abscess formation

35. III. DIAGNOSIS OF
PREDISPOSING LESIONS1. VALVULAR HEART DISEASE
 Native valve – BAV, MVP
 Rheumatic valve – MR/ AR
 Prosthetic valve – bioprosthetic / mechanical
 Tricuspid valve – IV abuse/ CV line
2. CONGENITAL HEART DISEASE :
VSD / PDA /COA
3. UNCOMMON LESIONS :
PS / ASD / HOCM /AV FISTULA

36. IV.EVALUATION OF RESPONSE TO
TREATMENT

37. V. PROPER TIMING OF SURGICAL
INTERVENTION
1. CHF secondary to valvular insufficiency, refractory to
medical therapy
2. Fungal IE
3. Persistent sepsis>72 hrs despite of appropriate
medical therapy
4. Valve dehiscence, rupture, abscess, fistula
5. AML infection in setting of Aortic Valve IE
6. Heart block caused by abcess
7. Prosthetic valve endocarditis
8. Highly mobile, large >10mm vegetation

38. Diagnostic Echo criteria
Characteristics of mass likely to be a vegetation:
 Texture: gray scale and reflectance of myocardium
 Location: upstream side of valve in path of jet or on
prosthetic material
 Motion: choatic and orbiting, independent of valve
motion
 Prolapse into upstream chamber (i.e. MV mass into LA in systole)

40. Diagnostic Echo criteria
Characteristics of mass likely to be a vegetation:
 Texture: gray scale and reflectance of myocardium
 Location: upstream side of valve in path of jet or on
prosthetic material
 Motion: choatic and orbiting, independent of valve
motion
 Prolapse into upstream chamber (i.e. MV mass into LA in systole)
 Shape: lobulated, amorphous
 Accompanying abnormalities:
 abscess, pseudoaneurysm, fistula, prosthetic dehiscence,
paravalvular leak, new regurgitant lesion

41. Diagnostic Echo criteria
Characteristics of mass unlikely to be vegetation:
 Texture: reflectance of calcium or pericardium (white)
 Location: outflow tract attachment, downstream surface
of valve
 Shape: stringy or hair-like strands with narrow
attachment
 Lack of accompanying turbulent flow or regurgitation

42. False Positives
 Most common on TEE
 Lambl’s excrescences
 Strands on sewing rings of prosthetics
 Free suture
 Redundant chordae, false tendons in LV
 Chiari’s remnant in RA
 Chordal insertion into normal MV
 All of above tend to be highly reflective with
echodensity similar to pericardium or aortic root.
Dense, fibrotic, non-vibratory nature

43. Mitral Valve Vegetation

44. Aortic vegetation

45. Aortic root abscess

46. Rupture of Sinus Valsalva

47. TEE MV PVE

48. Prosthetic valve Rocking
motion

49. Prosthetic valve dehiscence

50. Tricuspid Valve NVE

51. Libman-Sacks Endocarditis

54. False Negatives
 TTE>TEE
 High sensitivity of TEE (92-94%)
 Cannot definitively rule out endocarditis
 Low likelihood of IE if negative TEE in
intermediate probability patient
 In patients at high risk for IE (prosthetic valve,
unexplained bacteremia), repeat examination
reasonable

55. Intracardiac Complications
 Valvular regurgitation
 Secondary infection of other valves
 Leaflet perforation
 Perivalvular abscess or fistula
 Early invasion  cellulitis (echodense thickening of perivalvular tissue)
 Necrosis and inflammation  abscess cavity
 Abscess most likely with staph aureus
 Risk of fistula formation
 Abscess formation  increase in morbidity and mortality
 TEE >TTE: 118 pts with IE, 1991, 44 with abscess at surgery/autopsy. 87%
vs 28% sensitivity*
 TEE still imperfect. Additional series 2007 showed TEE detecting only 48%
of abscesses (21 of 44 pts)+
*Daniel, WG, Mugge, A, Martin, RP, et al. Improvement in the diagnosis of abscesses associated with endocarditis by transesophageal
echocardiography. N Engl J Med 1991; 324:795.
+Hill, EE, Herijgers, P, Claus, P, et al. Abscess in infective endocarditis: the value of transesophageal echocardiography and outcome:
a 5-year study. Am Heart J 2007; 154:923.

56. Thank you