Transthoracic and Transesophageal Echocardiography for the Indication of Suspected Infective Endocarditis: Vegetations, Blood Cultures and Imaging

J Am Soc Echocardiogr. 2010; 23(4):403-405

Kini V, Logani S, Ky B, Chirinos JA, Ferrari VA, St John Sutton MG, Wiegers SE, Kirkpatrick JN

OBJECTIVES: The aim of this study was to investigate the ability of transthoracic echocardiography (TTE) to detect vegetations and the relationship between blood cultures and transesophageal echocardiography (TEE).

METHODS: Five hundred eleven TTE and TEE pairs performed to evaluate endocarditis were retrospectively analyzed. Vegetation on TTE, prosthetic valve, change in regurgitation, and blood cultures were correlated with vegetation on TEE.

RESULTS: TTE detected 45% of vegetations seen on TEE. There was no difference for prosthetic valves. Prosthetic valves (odds ratio, 1.7; P = .03) and increased regurgitation (odds ratio, 1.7; P = .01) were associated with vegetations on TEE; staphylococcal bacteremia and fungemia were not. Negative blood cultures were associated with negative results on TEE (P < .0001), but 27% of patients with prosthetic valves had culture-negative endocarditis or nonbacterial thrombotic endocarditis, and 6% had abscesses missed by TTE.

CONCLUSIONS: This study demonstrates a limited capacity of TTE to detect vegetations. TEE may be an appropriate initial study to evaluate prosthetic valves. TEE for culture-negative endocarditis deserves further study.

PMID: 20138467

2 Responses

  1. Jacobo Kirsch, MD  on April 30th, 2010

    An important clinical pearl as concluded by the authors is that an increase in the severity of valvular regurgitation of >1 grade on TTE (under the right clinical context and without visualization of vegetation) should raise the concern and the need for a TEE.

  2. James Kirkpatrick  on May 3rd, 2010

    Endocarditis remains a difficult diagnosis to make, and it is not always clear the best course of action in using imaging. Index of suspicion remains the most important aspect of the clinical diagnosis, but we hope that our paper and others can contribute to an ongoing discussion about the appropriate use of TTE and TEE. We also hope to stimulate discussion about the use of imaging in diagnosing non-bacterial thrombotic and culture negative endocarditis.


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