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Role of echocardiography in infective endocarditis

Role of echocardiography in infective endocarditis
Literature review current through: Jan 2024.
This topic last updated: Aug 22, 2023.

INTRODUCTION — 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 as specified in the 2023 Duke-International Society for Cardiovascular Infectious Disease (ISCVID) criteria [1]. (See "Clinical manifestations and evaluation of adults with suspected left-sided native valve endocarditis", section on '2023 Duke-ISCVID criteria'.)

The use of echocardiography in IE will be reviewed here, with emphasis on the clinical issues of its application and its potential weaknesses and pitfalls. The clinical diagnostic approach to this disorder is discussed separately. (See "Clinical manifestations and evaluation of adults with suspected left-sided native valve endocarditis".)

GOALS OF ECHOCARDIOGRAPHIC EVALUATION — For patients undergoing echocardiography due to suspected IE, the goals of the echocardiographic evaluation include:

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) (see 'Recognition of intracardiac complications of endocarditis' below)

In addition, for patients with a cardiac implantable electronic device (ie, permanent pacemaker or implantable cardioverter-defibrillator) and transvenous leads terminating in the heart, an effort should be made to visualize as much of the leads as possible. (See "Infections involving cardiac implantable electronic devices: Epidemiology, microbiology, clinical manifestations, and diagnosis".)

COMPARING TTE AND TEE — Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) have complimentary roles in the diagnosis and evaluation of endocarditis. Performing an initial TTE is usually recommended, especially in individuals without a prior TTE. Even in individuals with prosthetic heart valves for whom the diagnosis is more challenging, a TTE is usually recommended as the first-line imaging test given its ease and availability and its value in obtaining infection-related functional findings [2]. The decision on when to use TEE is individualized, taking into account clinical risk factors, patient examination findings, laboratory data, and diagnostic quality of the TTE (algorithm 1).

Limitations of TTE — The transmission of ultrasound between the transducer and the heart by TTE is impeded by obesity, hyperinflated lungs during mechanical ventilation, narrow interspaces, valve/annular calcification, and valve prostheses. All of these factors may obscure the visualization of vegetations. TEE is less susceptible to these constraints and usually provides excellent image quality.

The accuracy of TTE for detecting vegetations in IE has been evaluated in a variety of studies (movie 1 and movie 2 and movie 3 and movie 4 and movie 5 and image 1A-B and image 2). The European Society of Cardiology (ESC) Guidelines have estimated the sensitivity of TTE for IE to be around 70 percent for native valves and 50 percent for prosthetic valves, with a specificity of approximately 90 percent [3]. A meta-analysis of 16 articles on TTE found similar values with sensitivity of 66 percent and a specificity of 95 percent for native valves [4]. Situations where TTE may not identify vegetations include poor acoustic windows, underlying valve thickening, valvular calcification, redundant leaflet tissue, prosthetic shadowing, or recent vegetation migration/embolization. The measurements of structures in echocardiographic studies are limited by image resolution. TTE underestimates the size and complexity of large vegetations and may fail to detect small vegetations (<3 mm in diameter).

The role of TEE in the diagnosis of IE is related to its superior visualization and spatial resolution leading to higher sensitivity in detecting and defining valve vegetations and other complications (movie 6 and movie 7 and movie 8 and movie 9 and movie 10 and image 3A-C). The sensitivity of TEE for vegetation is approximately 96 percent for native valves and 92 percent for prosthetic valves, and the specificity for both is approximately 90 percent [3]. The sensitivity and specificity of TEE for detecting an abscess is approximately 90 percent [3].

When is TTE likely diagnostic? — Strict TTE criteria, where a TEE is unlikely to yield additional diagnostic information among individuals with bacteremia, have been proposed after an analysis of 790 individuals with both TTE and TEE in suspected endocarditis. When the TTE had moderate or better ultrasound quality, normal anatomy, no valvular stenosis or sclerosis, less than mild valvular regurgitation, no significant pericardial effusion, no catheter or pacemaker leads, no prosthetic valve, and no evidence of vegetation, the negative predictive value of TTE was 97 percent [5]. The usefulness of strict negative criteria was validated by an observational study of over 900 echocardiograms from 2014 to 2018, of which 50 percent fulfilled strict negative criteria, and, among those, only 0.9 percent were given a diagnosis of IE [6].

3D echocardiography — Three-dimensional (3D) echocardiography (TTE or TEE) has the capability of offering spatial information about the size and attachment of vegetations and increased sensitivity for detecting and sizing abscess cavities [7-10]. 3D echocardiography also helps facilitate the diagnosis of prosthetic valve dehiscence (movie 11). However, 3D echocardiography is subject to constraints on image quality with less temporal or two-dimensional spatial resolution than TTE and TEE.

WHO NEEDS A TTE? — Multiple professional societies recommend a TTE for individuals with suspected IE [3,11]. A TTE provides an evaluation of ventricular function, chamber sizes, valvular morphology and valvular function, and hemodynamics.

Suspected IE – Suspected IE is based on Duke criteria. (See "Clinical manifestations and evaluation of adults with suspected left-sided native valve endocarditis", section on '2023 Duke-ISCVID criteria'.)

For an individual with positive blood cultures, new or worsening regurgitant murmur, or with minor criteria of predisposing conditions, fever, vascular phenomena, and/or immunologic phenomena, a TTE is an important initial diagnostic step. In general, echocardiography may not be appropriate for suspected endocarditis if fever is the only indication.

Changing clinical presentation or high risk for complications – A TTE is also recommended for reevaluation for individuals with suspected IE with a change in signs or symptoms (eg, new murmur, embolism, persistent fever, heart failure, abscess, or atrioventricular heart block) and in patients at high risk of complications (eg, extensive infected tissue/large vegetation on initial echocardiogram or staphylococcal, enterococcal, or fungal infections).

When to repeat TTE – There is debate on the timing of follow-up TTE for individuals with continued suspicion for IE despite negative initial examination. Occasionally, a valvular vegetation may be too small on initial examination and may grow over time. In our clinical practice, we evaluate for a change in signs or symptoms on an ongoing basis, and we would usually wait approximately three to five days before repeating a study in stable patients if there are no other changes. For an individual with a large vegetation, where change in size of vegetation is a factor influencing the potential need for surgery, more frequent limited follow-up TTE may be considered especially if there is clinical progression (eg, development of heart block, heart failure, ongoing bacteremia, etc) that indicates a need for surgery.

The role of follow-up echocardiography in patients diagnosed with IE is discussed below. (See 'Follow-up echocardiograms' below.)

WHO NEEDS A TEE? — The implications of an initial TTE examination that fails to show vegetations in a patient with suspected IE should be carefully considered. If there is high clinical suspicion, a TEE should be performed (algorithm 1). The sensitivity of TEE has been reported as 92 to 96 percent [12-16]. Although TEE cannot definitively exclude endocarditis, its high diagnostic sensitivity results in a low probability of the disease when negative results are obtained in a patient with an intermediate likelihood of the disease [3,11,17].

TEE is recommended in patients with high clinical suspicion of IE and a negative or nondiagnostic TTE.

TEE is recommended in all patients with known or suspected endocarditis when complications have developed or are clinically suspected, or when intracardiac device leads are present.

TEE is reasonable to diagnose possible IE in patients with Staphylococcus aureus bacteremia without a known source.

TEE is reasonable to diagnose IE of a prosthetic valve in the presence of persistent fever without bacteremia or a new murmur.

Repeat TEE examination may sometimes be necessary and relevant as vegetations or abscesses may develop and grow over time. Consideration of repeat TEE at four to five days should be considered, particularly in patients at high risk for IE, such as those with a prosthetic valve, community-acquired bacteremia without known source, or persistent bacteremia [14].

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).

There is debate on whether TEE is necessary for evaluation of all Staphylococcus aureus bacteremia. Risk factors where TEE is more likely to identify IE are:

Abnormal TTE.

Community-acquired infection.

Intravenous drug use.

High-risk cardiac conditions, defined as prosthetic heart material, congenital heart disease, cardiac transplantation, history of endocarditis, or presence of a cardiac device [18].

Prolonged S. aureus bacteremia >72 hours [19].

DIFFERENTIAL DIAGNOSIS OF CARDIAC MASSES IDENTIFIED BY ECHOCARDIOGRAM — False positives on echocardiography arise because small, previously invisible irregularities and degenerative processes are clearly seen in magnified format [12].

Tiny mobile strands are frequently encountered on the valves; these strands probably represent a normal degenerative process and are known as Lambl excrescences.

Strands, possibly from the same source, can also arise on the sewing ring of prosthetic valves. In addition, a free suture end can occasionally be visualized and may be mistaken for a pathologic finding. Amputated chords after valve surgery may also cause linear independently mobile echodensities near the mitral or tricuspid valves.

Redundant chordae or false tendons in the left ventricle, the valve of the inferior vena cava (Eustachian valve), or the Chiari network in the right atrium may be mistaken for vegetative masses.

Chordal insertion into normal mitral valve margins may mimic a mass. 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. (See "Nonbacterial thrombotic endocarditis".)

Valvular disruption from trauma or other causes may also cause significant regurgitation and be confused with IE.

Some vegetations persist after bacterial cure has been achieved and remain stable in size for many years [20]. However, chronic lesions are more echogenic than acute vegetations [21].

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

DIAGNOSIS OF INFECTIVE ENDOCARDITIS — The 2023 Duke-International Society for Cardiovascular Infectious Disease (ISCVID) criteria for diagnosis of IE include the following echocardiographic findings as major criteria [1] (see "Clinical manifestations and evaluation of adults with suspected left-sided native valve endocarditis", section on '2023 Duke-ISCVID criteria'):

Echocardiography and/or cardiac CT demonstrating vegetation, valvular/leaflet perforation, valvular/leaflet aneurysm, abscess, pseudoaneurysm, or intracardiac fistula

Significant new valvular regurgitation on echocardiography, compared with previous imaging; worsening or changing of pre-existing regurgitation is not sufficient

New partial dehiscence of prosthetic valve (compared with previous imaging)

Less common echocardiographic findings of IE include pseudoaneurysm, fistula, or valve perforation. New valvular regurgitation is a major criterion in the American Heart Association (AHA) Valvular Heart Disease Guideline and AHA Scientific Statement [11,17].

With either transthoracic or transesophageal methods, 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 [22]:

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 and orbiting; independent of valve motion.

Shape – Lobulated and amorphous.

Accompanying abnormalities – Abscess and pseudoaneurysm, fistulae, prosthetic dehiscence, paravalvular leak, significant preexisting or new regurgitation.

Vegetations also characteristically prolapse into the upstream chamber: mitral vegetations into the atrium in systole and aortic vegetations into the left ventricular outflow tract during diastole. Vegetations tend to flank the regurgitant jet. Intracardiac foreign structures, such as pacemaker leads, must also be interrogated for the presence of a vegetation [23].

While the following grading system is not formally used in clinical practice, it identifies factors that can indicate high risk of embolism. Larger size, highly mobile, less dense, and greater extension of vegetations indicate a higher risk of complication [24]. Masses have been analyzed according to four properties [22]:

Size – Established by the two largest orthogonal diameters

Mobility – Defined as: grade 1, fixed; grade 2, fixed base free edge; grade 3, pedunculated; grade 4, prolapsing

Density – Defined as: grade 1, calcified; grade 2, partially calcified; grade 3, denser than myocardium but not calcified; grade 4, equivalent to myocardium

Extent – Defined as: grade 1, single; grade 2, multiple on a single leaflet; grade 3, multiple leaflets; grade 4, extending to extravalvular structures

PROGNOSTIC MARKERS — Vegetation size in its longest dimension appears to be the most powerful predictor of complications, although mobility and which valve is affected also appear to play a role. (See "Complications and outcome of infective endocarditis".)

In one retrospective cohort study, the probability of sustaining a complication was 10 percent when vegetations were 6 mm in size, 50 percent for lesions of 11 mm, and almost 100 percent for lesions ≥16 mm [22]. There were significantly fewer complications in patients without discernible valvular abnormalities (27 percent). Additionally, larger vegetation size appears to be predictive of embolic risk [25-27].

In a study of 105 patients with IE, patients with a vegetation diameter above 10 mm had a significantly higher incidence of embolic events than did those with smaller vegetations (47 versus 19 percent), particularly with mitral valve vegetations [25].

In a series of 178 patients with definite IE who underwent TEE, the incidence of embolism, as diagnosed by cerebral and thoracoabdominal CT scans, was higher when vegetation size was ≥15 mm (70 versus 27 percent for <15 mm) and when the vegetation was moderately or severely mobile (62 versus 20 percent for low mobility) [28].

Observational studies suggest that embolic risk generally falls with time after institution of appropriate antibiotic therapy. In a series of 1437 patients from the International Collaboration on Endocarditis, the embolic stroke rate decreased from 4.8 to 1.7 per 1000 patient years from the first to the second week of antibiotic treatment [29]. Among 178 patients with definite IE, only 24 percent of observed emboli occurred after the start of antibiotic therapy, but greater vegetation length and mobility were still prognostic factors for these later embolic events [28].

RECOGNITION OF INTRACARDIAC COMPLICATIONS OF ENDOCARDITIS — In addition to its role in diagnosing endocarditis, echocardiography is important for recognizing the intracardiac complications associated with endocarditis, including valvular regurgitation, valve perforation, and abscess and fistula formation. (See "Complications and outcome of infective endocarditis".)

Valvular regurgitation — Bacterial infiltration and proliferation in valve tissue can destroy the leaflet integrity, leading to regurgitation (movie 3). In general, the etiology of valve deterioration has little impact on the echocardiographic features of severe valvular regurgitation. However, it is sometimes difficult to differentiate a disrupted, prolapsing and flail segment of leaflet from a mobile prolapsing vegetation. Each has the same motion during the cardiac cycle, echocardiographic tissue characteristics are similar, and both may be present in the same location. Mistaking a flail leaflet for a vegetation may lead to miscalculation of risk level or overdiagnosis of endocarditis. TEE substantially aids distinguishing a flail leaflet from vegetation, and this capacity contributes to its advantages as a prognostic and diagnostic tool.

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 (image 3C). Abscess formation is most likely with S. aureus infection.

Since the myocardial wall is under considerable pressure, the weakened necrotic tissue may become disrupted and the abscess cavity may communicate with either ventricle or a great vessel (movie 6). In the setting of such a communication, the abscess cavity can also be viewed as a pseudoaneurysm, particularly if it involves the aortic wall directly [30]. The distinction between an abscess and pseudoaneurysm can be made with TEE color flow Doppler, which will demonstrate flow into a pseudoaneurysm but not into an abscess [31].

Clinical manifestations — The most important feature of myocardial abscess formation is the increased morbidity and mortality (32 to 45 percent in different series) associated with this complication [32,33]. Complete disruption of the aortic, atrial, and/or ventricular wall may lead to a fistulous connection with intracardiac shunting between chambers, most commonly between the aorta and either atrium causing a continuous murmur, between either atrium and either ventricle causing a systolic murmur, or between the left ventricle and right ventricle. If the abscess extends into the septum, the conduction system may be interrupted or conduction slowed; a right bundle branch block with first degree AV block may ensue [34]. Presence of an abscess is an indication for surgery. (See "Complications and outcome of infective endocarditis", section on 'Perivalvular abscess'.)

Detection — TEE has a much greater likelihood of detecting a myocardial abscess than TTE (image 3C). One study, for example, evaluated 118 patients with endocarditis, 44 (37 percent) of whom had an abscess documented at surgery or autopsy [32]. The sensitivity and specificity of TEE were 87 and 95 percent, respectively; the sensitivity of TTE was much lower (28 versus 87 percent with TEE) although the specificity was 99 percent. A similar wide discrepancy in sensitivity (25 versus 100 percent with TEE) was noted in another report [35]. TTE is most effective for detecting an anterior abscess at the aortic septal junction because of transducer proximity to this region.

While TEE is more sensitive than TTE for detecting an abscess, even TEE may miss an abscess in some populations. This was illustrated in a report of 44 patients with surgically identified abscesses [36]. Only 21 (48 percent) were detected by TEE. Sixty-one percent of missed abscesses were located at the posterior mitral annulus, and the majority of these were associated with a large calcification that may have interfered with abscess detection.

The likelihood of detection of periaortic annular abscess by TEE in patients with aortic endocarditis was studied by the International Collaboration of Endocarditis merged database [37]. Of 311 patients in the database, 22 percent had abscesses. The abscess was more likely to occur in the setting of a prosthetic valve (40 versus 19 percent) with coagulase-negative staphylococcal IE. Surgery was more likely, and mortality in hospital was higher (19 versus 11 percent).

Other imaging for aortic abscess (eg, cardiac computed tomography) is discussed separately. (See "Prosthetic valve endocarditis: Epidemiology, clinical manifestations, and diagnosis", section on 'Additional imaging tools'.)

Other complications — Other complications that are best detected with TEE include leaflet perforation (movie 12), true aneurysm formation, secondary infection of other valves resulting from vegetation contact (for example secondary mitral valve involvement with primary aortic valve endocarditis) [38], and vegetations on the chamber walls that are struck by the jets of blood passing through the infected valves. As an example, one study that correlated the results of TTE and TEE with anatomic findings at surgery in 88 valves from patients with endocarditis, the sensitivity of TEE for the detection of valve perforation was significantly higher than that of TTE [39]. TEE detected perforation in 21 of 22 cases compared with only 10 of 22 by TTE.

MANAGEMENT IMPACT OF ECHOCARDIOGRAPHIC FINDINGS — Echocardiographic findings can identify individuals who may benefit from surgery, especially those with heart failure related to the infected valve or findings of uncontrolled infection. Size of the vegetation as an indicator of embolic risk may also be considered, though surgery for the isolated reason of vegetation size is not routine in clinical practice [40,41]. Observational data demonstrate a high mortality for individuals with an indication for surgery who are managed medically [42].

The AHA identifies the following echocardiographic features of vegetations that suggest potential need for surgical intervention [17]:

Persistent vegetation after systemic embolization

Anterior mitral leaflet vegetation, particularly >10 mm

Increase in vegetation size despite appropriate antimicrobial therapy

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 [3].

The surgical management of IE is discussed in detail separately. (See "Surgery for left-sided native valve infective endocarditis" and "Surgery for prosthetic valve endocarditis".)

FOLLOW-UP ECHOCARDIOGRAMS — Patients who are diagnosed with definite IE will require ongoing surveillance echocardiograms to assess the impact of therapy and for the development of complications (eg, abscess, fistula, valve perforation, etc).

Repeat imaging with TTE or TEE is indicated when there is a change in clinical signs or symptoms, such as a new murmur, embolism, persistent fever, heart failure, or sign of heart block [11].

Repeat TTE and/or TEE should be considered during follow-up of uncomplicated IE in order to detect new silent complications and monitor vegetation size. The timing and mode of repeat examination depend on the initial findings, type of microorganism, and initial response to therapy.

It is our practice to repeat the TTE or TEE after seven days of antibiotic therapy and compare the size of the vegetation(s); dramatic decreases in vegetation size may occur after only one week of treatment.

TTE is recommended at completion of antibiotic therapy for evaluation of cardiac and valve morphology and function. We typically repeat a TTE within one to two weeks after the completion of antibiotics. This evaluates the severity of residual regurgitation and the extent and size of residual vegetations, if present. If there is future concern for recurrent endocarditis, comparison with the echocardiogram after completion of therapy can be useful.

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. If new valvular dehiscence is identified in any individual, even without obvious sign of infection, blood cultures should be considered. 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. If prior data are lacking, moderate to severe but not mild paravalvular regurgitation should be considered suggestive of endocarditis [43].

The use of TTE for detecting prosthetic valve endocarditis is impeded by suboptimal visualization because prosthetic materials are highly reflective and usually block the passage of ultrasound. As a result, prosthetic valves shadow or obscure structures lying behind the valve. As an example, it is usually impossible to image the atrial side of the mitral prosthesis or the arterial side of the aortic prosthesis from an apical TTE window.

TEE solves this problem for mitral prostheses and improves it for aortic prostheses (movie 9 and movie 10). 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.

One feature of prosthetic valve endocarditis that should be evaluated by echocardiography but may be missed is prosthetic valve dehiscence (movie 11). In a study that included 26 patients with prosthetic valve endocarditis, 14 (54 percent) had surgically identified valve dehiscence [36]. Dehiscence was missed on TEE in four cases that all involved an aortic prosthetic valve. (See "Prosthetic valve endocarditis: Epidemiology, clinical manifestations, and diagnosis", section on 'Echocardiography'.)

In cases of possible prosthetic valve endocarditis where echocardiography is not definitive, other imaging modalities such as cardiac computed tomography or nuclear imaging (with 18F-FDG PET) may help confirm or reject endocarditis [3]. (See "Prosthetic valve endocarditis: Epidemiology, clinical manifestations, and diagnosis", section on 'Diagnosis'.)

SUMMARY AND RECOMMENDATIONS

Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) have complimentary roles in diagnosis and evaluation of infective endocarditis (IE). (See 'Comparing TTE and TEE' above and 'Who needs a TTE?' above and 'Who needs a TEE?' above.)

For most patients with suspected IE, an initial TTE is usually recommended, especially in individuals without a prior TTE.

When the TTE is nondiagnostic or if there is high clinical suspicion for IE, a TEE is recommended (algorithm 1).

TEE is recommended as the initial test for individuals with suspected IE involving a prosthetic heart valve in any location.

Repeat TTE/TEE may be necessary in four to five days if IE is suspected and not identified by initial examination.

For those with a vegetation, a TEE is often recommended to evaluate the extent of infection and potential of abscess. (See 'Who needs a TEE?' above.)

A variety of other findings may be mistaken for an infective vegetation, including Lambl excrescences, other cardiac masses, sutures, chordae tendineae, annular calcification, thrombus, and occasional valvular prolapse. (See 'Differential diagnosis of cardiac masses identified by echocardiogram' above.)

In addition to its role in diagnosing endocarditis, echocardiography is important for recognizing the intracardiac complications associated with endocarditis, including regurgitant valve lesions, valve perforation, and abscess and fistula formation. Echocardiographic findings that suggest a need for surgery are severe valvular regurgitation with signs of heart failure, abscess, large vegetation, prosthesis dehiscence, or increase in vegetation size despite appropriate antibiotic therapy. (See 'Recognition of intracardiac complications of endocarditis' above and 'Management impact of echocardiographic findings' above.)

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Topic 5323 Version 22.0

References

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