Echocardiography plays a key role in the diagnosis and management of infective endocarditis. It can identify valvular vegetations, abscesses, fistulas and other complications. The presence of an oscillating intracardiac mass or abscess on valves or endocardial surfaces are major echocardiographic criteria for the diagnosis. Transesophageal echocardiography is recommended if transthoracic is nondiagnostic or for complications. Follow up echos are important to monitor vegetation size with treatment and check for complications. Differentiating infective vegetations from other intracardiac masses or artifacts is important.

1. Echocardiography in infective
endocarditis
Dr. Sruthi Meenaxshi MBBS ,MD ,PDF

2. What is infective endocarditis?
• Infection of the endocardium, or lining layer of the heart, can
occur on any surface, including valve leaflets, congenital
defects, the walls or chordae of the chambers, prosthetic tissue,
or the attachment of implanted shunts, conduits, and fistulae.
• The clinical diagnosis of infective endocarditis (IE) is based
upon a combination of features such as positive blood cultures,
echocardiographic findings, and other clinical or laboratory
criteria

6. ROLE OF ECHO
●Determining the underlying anatomy of the valvular structures
(and comparing with prior studies, when available)
●Determining the presence, location, size, and number of
vegetation-like masses
●Defining any functional valvular abnormalities/dysfunction
resulting from vegetation(s) and leaflet damage
●Determining the impact of valvular abnormalities/dysfunction, if
any, on right and left ventricular size and function
●Detecting complications of IE (eg, abscess, fistula, etc)

7. Modified dukes criteria for diagnosis of
infective endocarditis

9. Diagnosis of infective endocarditis
• Three echocardiographic structural findings as major criteria:
• presence of an oscillating intracardiac mass,
• presence of an abscess, or
• partial dehiscence of a prosthetic valve
• Less common echocardiographic findings of IE include
• pseudoaneurysm,
• fistula, or valve perforation.
• New valvular regurgitation(AHA)

11. WHO NEEDS TEE
TEE is recommended in patients with high clinical suspicion of IE and
a negative or nondiagnostic TTE.
all patients with complications or if intracardiac device leads are
present
in case of staphylococcal bacterimia with unknown source
in patients with prosthetic valve with persistent fever in absence of
bacteremia or new murmur
Repeat TTE and/or TEE are recommended as soon as a new
complication of IE is suspected (new murmur, embolism, persisting
fever, heart failure, abscess, atrioventricular block).

12. VEGETATION DEFINITION
• a valvular vegetation is defined as "a discrete mass of echogenic
material adherent at some point to a leaflet surface and distinct in
character from the remainder of the leaflet" based upon the following
characteristics
• Texture – Gray scale and reflectance of myocardium
●Location – Upstream side of the valve in the path of the jet or on
prosthetic material
●Characteristic motion – Chaotic; independent of valve motion
●Shape – Lobulated and amorphous
●Accompanying abnormalities – Abscess and pseudoaneurysm,
fistulae, prosthetic dehiscence, paravalvular leak, significant
preexisting or new regurgitation

13. • Vegetations also characteristically prolapse into the upstream
chamber
• Vegetations tend to flank the regurgitant jet
• . Intracardiac foreign structures, such as pacemaker leads,
must also be interrogated for the presence of a vegetation
These vegetations should be examined carefully because of greater risk
of embolism.
Size of the vegetation should be noted taking two largest orthogonal
diameter

14. Mobility, density and extent of vegetation
should be graded
Grade 1 Grade2 Grade3 grade4
MOBILITY fixed Fixed base and
free edge
pedunculated prolapsing
DENSITY Calcified Partial calcified Denser than
myocardium not
calcified
Equal to
myocardium
EXTEND Single Multiple in single
leaflet
Multiple leaflet Extended to
extravalvular
structures

15. RECOGNITION OF INTRACARDIAC
COMPLICATIONS OF ENDOCARDITIS
• valvular regurgitation
• valve perforation
• abscess
• fistula formation

16. Valvular regurgitation —
• Bacterial infiltration and proliferation in valve tissue can destroy
the leaflet integrity, leading to regurgitation
• Must be differentiated from a disrupted prolapsing and flail
leaflet
Perivalvular abscess or fistula — When the infective process
spreads beyond the valve leaflets or the cavitary endocardium, it
invades the continuous basal myocardium and tissue of the
fibrous cardiac skeleton.
Early in this process, the organism produces cellulitis, which may
be identified as echodense thickening of perivalvular tissue.
If tissue necrosis and white cell activity continue, the central
portion of this process forms a space-occupying abscess
cavity
Abscess formation is most likely with S. aureus infection.

20. Large oscillating intracardiac mass suggestive
of infective etiology

21. AHA identifies the following
echocardiographic features of vegetations
that suggest potential need for surgical
intervention
• Persistent vegetation after systemic embolization
• Anterior mitral leaflet vegetation, particularly >10 mm
• Increase in vegetation size despite appropriate antimicrobial
therapy

22. ESC when surgery is indicated ?
The ESC identifies symptomatic heart failure or
echocardiographic signs of poor hemodynamic tolerance
as indicators for surgery associated with echocardiographic
findings of left-sided severe regurgitation, obstruction, or
fistula formation.
 If the hemodynamic abnormality is acute and associated with
shock, then emergency surgery is indicated [3].
By the ESC recommendations, surgery should be considered
for native valve aortic or mitral vegetations >10 mm with low
operative risk or for very large vegetations >30 mm

23. FOLLOW UP ECHOCARDIOGRAM
• To assess for the development of complications (eg, abscess,
fistula, valve perforation, etc).
• After 7 days of medical therapy to compare vegetation size
• At completion of antibiotic therapy for evaluation of cardiac function
and valve morphology

26. Large vegetation over the tricuspid leaflet

27. Echocardiographic image of infective
endocarditis over the pulmonary valve

30. PROSTHETIC VALVE ENDOCARDITIS
• Prosthetic valve dehiscence is highly suggestive of IE.
• Dehiscence can be the only manifestation of IE with a prosthetic
valve in the absence of vegetation or abscess
• A valve rocking motion may indicate valve dehiscence.
• Paravalvular regurgitation may also indicate prosthetic valve
endocarditis but should be compared with any prior paravalvular
regurgitation
• TEE solves this problem for mitral prostheses and improves it for
aortic prostheses .However, when both mitral and aortic prostheses
are present, the mitral device tends to obscure the aortic valve.
Tricuspid and pulmonic devices pose similar problems.

33. DIFFERENTIAL DIAGNOSIS OF CARDIAC
MASSES IDENTIFIED BY ECHOCARDIOGRAM
●Tiny mobile strands are frequently encountered on the valves; these strands
probably represent a normal degenerative process and are known as Lambl's
excrescences.
The valve of the inferior vena cava (Eustachian valve), or the Chiari network in
the right atrium may be mistaken for vegetative masses.
Prolapse of the mitral valve may also in some views be confused with a
vegetation.
●Annular calcification (typically the mitral annulus) can protrude into the cardiac
chambers and raise the possibility of a vegetation.
●Thrombus and tumor should also be considered among the differential diagnosis
of intracardiac echodensities.
A papillary fibroelastoma is a tumor that may be encountered on valve tissues.
Non-bacterial thrombotic endocarditis should also be considered
●Valvular disruption from trauma or other causes may also cause significant
regurgitation and be confused with IE.

34. Lambl's excrescences

35. CHIARI NETWORK

36. LV APICAL THROMBUS

37. RV THROMBUS

38. MITRAL ANNULAR CALCIFICATION

39. Characteristics of a mass not likely to be
an acute vegetation include
●Texture – reflectance of calcium or pericardium (appears 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