From the Guidelines
When using transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) to investigate mitral regurgitation (MR) resulting from infective endocarditis, the most important values to report include the severity of regurgitation, vegetation characteristics, and valvular damage assessment.
Key Parameters to Report
Specifically, clinicians should quantify MR severity using:
- Regurgitant volume
- Regurgitant fraction
- Effective regurgitant orifice area
- Vena contracta width For vegetation assessment, report:
- Size (with dimensions in mm)
- Mobility
- Location
- Number of vegetations Valvular damage should be characterized by documenting:
- Leaflet perforations
- Flail segments
- Ruptured chordae
- Any abscess formation or fistula development Hemodynamic consequences should be assessed through:
- Left atrial size
- Left ventricular dimensions and function
- Pulmonary artery pressure estimates Additionally, report any paravalvular extension of infection including:
- Annular abscesses
- Pseudoaneurysms
- Fistulae These parameters are crucial as they directly impact management decisions, including timing of surgical intervention, antibiotic selection, and prognosis, as highlighted in recent guidelines 1.
Role of TEE and TTE
TEE provides superior visualization of posterior structures and is particularly valuable for detecting small vegetations (<3mm), perivalvular complications, and precise vegetation characterization that might be missed on TTE, making both modalities complementary in comprehensive assessment of endocarditis-related MR 1.
Clinical Implications
The ability of echocardiographic features to predict embolic events is limited, but large vegetations and severe valvular insufficiency are associated with a higher risk of complications, as noted in studies on infective endocarditis management 1.
Recommendations
Given the importance of accurate diagnosis and assessment of MR severity in infective endocarditis, clinicians should prioritize the use of both TTE and TEE to guide management decisions, considering the strengths and limitations of each modality, as supported by the most recent evidence 1.
From the Research
Important Values to Report when Using TTE and TEE to Investigate MR
When using Transthoracic Echocardiography (TTE) and Transesophageal Echocardiography (TEE) to investigate Mitral Regurgitation (MR) resulting from infective endocarditis, the following values are important to report:
- Valve structure
- Cardiac remodeling
- Color and spectral Doppler parameters 2
- Quantitative measurements, including:
- Effective regurgitant orifice area
- Regurgitant volume
- Regurgitant fraction 2
- Mechanism and grade of MR, which can be unclear from TTE alone and may require further evaluation with TEE or cardiac magnetic resonance imaging 2
- Presence of vegetations, valve perforation, and abscess formation, which can be detected using TEE 3
- Severity of MR, which can be classified as mild, moderate, or severe, and is essential for determining the best therapeutic option 2, 4
Role of Echocardiography in MR Evaluation
Echocardiography plays a key role in the diagnosis, prognostic assessment, and choice of therapeutic option in patients with mitral valve endocarditis 4. TTE is the initial modality for MR evaluation, while TEE is used for further evaluation when the mechanism and/or grade of MR is unclear from TTE or is discrepant with the clinical scenario 2.
Therapeutic Options
Surgery is frequently necessary in patients with MR resulting from infective endocarditis, and must be performed early in the course of the disease 4. Mitral valve repair is the best therapeutic option, when technically possible 4.