From the Guidelines
Transesophageal echocardiography (TEE) is the modality of choice for identifying right heart endocarditis lesions, as it provides superior visualization of cardiac structures compared to transthoracic echocardiography (TTE). According to the most recent guidelines, TEE is recommended for patients with intermediate or high probability of endocarditis, including right-sided endocarditis 1. The American College of Radiology also suggests that TEE is the procedure of choice for patients with intermediate or high probability of endocarditis, as it has a higher sensitivity for detecting vegetations and other complications of endocarditis.
Some key points to consider when using TEE for right heart endocarditis include:
- TEE provides higher-resolution images compared to TTE, allowing for better assessment of vegetation size, mobility, and extension
- TEE is particularly useful for visualizing lesions on the tricuspid valve, which may be smaller or more difficult to visualize with standard imaging
- The European Society of Cardiology recommends TEE for all patients with clinical suspicion of infective endocarditis and a negative or non-diagnostic TTE 1
- The American College of Cardiology/American Heart Association Task Force on Practice Guidelines also recommends TEE for assessing the severity of valvular lesions in symptomatic patients with infective endocarditis, if TTE is nondiagnostic 1
Overall, TEE is the preferred modality for identifying right heart endocarditis lesions due to its superior visualization and higher sensitivity for detecting complications of endocarditis. While TTE may be used as an initial screening tool, TEE should be pursued when clinical suspicion for endocarditis remains high despite negative or inconclusive TTE findings, especially in patients with prosthetic valves, poor acoustic windows, or suspected complications 1.
From the Research
Echocardiography in Right Heart Endocarditis
- Echocardiography is the gold standard for diagnosis of infective endocarditis (IE), including right-sided IE, with a sensitivity of 80% for transthoracic modality and 95% for transesophageal studies 2.
- The diagnostic yield of transthoracic echocardiography is comparable with that of transesophageal echocardiography in intravenous drug users with right-sided endocarditis 3.
- However, transesophageal echocardiography may not improve the diagnostic accuracy of transthoracic echocardiography in the detection of vegetations associated with right-sided endocarditis in intravenous drug abusers 4.
- Transesophageal echocardiography is mandatory in patients with cardiac devices and may be more sensitive than transthoracic echocardiography in identifying valvular vegetations, especially smaller ones (< 1 cm) 5.
Modality of Choice
- The modality of choice for identifying right heart endocarditis lesions may depend on the patient population and specific clinical scenario.
- For patients without prosthetic valves, harmonic transthoracic echocardiography may have a high negative likelihood ratio, making it useful for ruling out IE in certain cases 6.
- However, transesophageal echocardiography is generally considered more sensitive and specific for detecting valvular vegetations and diagnosing IE, especially in patients with cardiac devices or complex cases 2, 5.