Echocardiographic Reporting of Bacterial Endocarditis
The 2-D echocardiography conclusion report should explicitly state the presence of vegetations (mobile, echogenic masses attached to valve leaflets or endocardium), specify their size, location, and mobility, and document any associated complications such as valve perforation, abscess formation, or dehiscence. 1
Key Findings to Report in the Conclusion
Primary Diagnostic Features
The echocardiographic report must document vegetations as the hallmark finding, described as mobile, echogenic (echodense) masses attached to valvular leaflets or mural endocardium. 2, 1 These are the major echocardiographic criteria that carry primary diagnostic weight in the modified Duke criteria for infective endocarditis. 2
Critical vegetation characteristics to include:
- Size measurement (particularly important if >10 mm, which indicates high embolic risk) 2, 1
- Location (anterior mitral leaflet vegetations carry highest risk) 2, 1
- Mobility (degree of movement during cardiac cycle) 1
- Attachment site (valvular leaflet vs. mural endocardium) 2
Valvular Complications
The report should explicitly state any valvular destruction or dysfunction:
- Valve perforation (described as interruptions in valve tissue continuity with abnormal flow on color Doppler) 1
- Degree and mechanism of regurgitation (acute aortic or mitral insufficiency) 2
- Valve rupture 2
- Prosthetic valve dehiscence (excessive mobility during cardiac cycle) 2, 1
Perivalvular Extension
Document any perivalvular complications with specific terminology:
- Abscess formation (thickened, non-homogeneous perivalvular areas with echodense or echolucent appearance) 2, 1
- Pseudoaneurysms (pulsatile perivalvular echo-free spaces with flow on color Doppler) 1
- Fistulous tracts (abnormal communications between cardiac chambers) 2, 1
Reporting Algorithm Based on Valve Type
Native Valve Endocarditis
For native valves, TTE has approximately 70-75% sensitivity for detecting vegetations. 1, 3 The report should state whether vegetations are clearly visualized, suspected but not definitive, or not seen. 2 If vegetations are not clearly identified but clinical suspicion remains high, the report should recommend TEE for further evaluation. 2
Prosthetic Valve Endocarditis
For prosthetic valves, the report must be more cautious given TTE's limited 50% sensitivity. 1, 3 Even if no vegetations are seen on TTE, the conclusion should state that TEE is mandatory for definitive evaluation when prosthetic valve endocarditis is suspected. 1, 3 Document any prosthetic valve dehiscence or paravalvular leak. 2
Hemodynamic Assessment
The conclusion must include:
- Severity of valvular regurgitation or stenosis 2
- Left ventricular function (LVEF <40% is an independent predictor of mortality) 1
- Signs of ventricular decompensation or heart failure 2
Critical Pitfalls to Avoid
Do not use vague terminology. Avoid phrases like "possible vegetation" or "cannot exclude endocarditis" without providing specific guidance. 2 Instead, describe exactly what is seen and recommend the next diagnostic step (typically TEE if TTE is non-diagnostic). 2
Acknowledge limitations explicitly. If acoustic windows are poor, prosthetic material causes shadowing, or vegetations may be too small to detect (<2-3 mm), state this in the conclusion. 1, 3 The report should note that echocardiography does not supplant clinical and microbiological diagnosis. 2
For negative studies with high clinical suspicion, the conclusion should recommend repeat TEE in 3-5 days, as small vegetations may initially be below detection thresholds and abscesses may appear only as nonspecific thickening before becoming recognizable. 2, 4
Prognostic Information
When present, document features that predict need for surgical intervention: