Table 1.

Overview of imaging modalities in the detection of prosthetic valve endocarditis.

Imaging Modality	Advantages	Limitations	Test characteristics	Other considerations
TTE	• Non-invasive • Fast and cost effective • Provides both functional and anatomic data • Accessible technology/can be performed at bedside • Does not use radiation	• Limited sensitivity in PVE • Limited sensitivity in detecting abscesses and paravalvular involvement • Unable to assess for extracardiac manifestations	• Sensitivity for NVE 50–90% • Specificity for NVE >90% • Sensitivity for PVE 36–69%	• Useful and cost effective first line test for suspected IE
TEE	• Improved sensitivity over TTE for NVE and PVE • Provides both functional and anatomic data • Can be performed at bedside • Does not use radiation	• Semi-invasive • Procedural risks including sedation-related, aspiration, aerosolization, oropharyngeal-esophageal injury • Reduced sensitivity in PVE compared to NVE • Limited sensitivity in detecting abscesses and paravalvular involvement, possibly earlier on in disease course • Unable to assess for extracardiac manifestations	• Sensitivity for NVE of 90–100% • Sensitivity for PVE 82–96% • Specificity for IE 92–95%	• Appropriate second test if TTE is negative or inconclusive and clinical suspicion remains high
Leukocyte Scintigraphy	• High specificity for infection • Ability to assess paravalvular complications • Ability to assess extracardiac manifestations • Relatively wide availability (compared to PET/CT) and low cost	• Decreased sensitivity for detection of vegetations • Labor intensive, requires multiple sessions • Radiation exposure	• Sensitivity for IE 64–90% Specificity for IE 100% • Sensitivity for Abscess 83–100% • Specificity for Abscess 78–87%	• Useful test when high specificity is desired or for examining extracardiac manifestations of IE
FDG-PET	• High sensitivity in PVE • Enhanced anatomic resolution relative to leukocyte scintigraphy • Ability to assess paravalvular complications • Ability to assess for extracardiac manifestations	• Lower specificity—non-infectious inflammation can lead to false positives • Limited sensitivity in NVE • Radiation exposure • Dietary restrictions necessary for preparation	• Sensitivity for IE 73–100% • Specificity for IE 71–100%	• Useful test to follow a non-diagnostic TEE when clinical suspicion for PVE remains high
MDCTA	• Provides detailed anatomic data on coronary vasculature and valvular anatomy which can aid in perioperative planning • High sensitivity for paravalvular complications	• Limited ability to detect valve perforations and dehiscence • Limited ability to detect small vegetations • Risk of contrast induced nephropathy • Radiation exposure	• Sensitivity for IE 93–100% • Specificity for IE 83–97%	• May be ideal when both diagnostic and perioperative anatomic data are needed • Performance may be optimal when paired with tests with functional information such as echocardiography or FDG-PET
CMRI	• Provides highly detailed anatomic and functional data • May offer sensitivity to detect even small vegetations • Does not use radiation	• Not well-studied for detection of IE and limited data on ideal application • Artifacts or incompatibility from mechanical/ferromagnetic implants	• Limited data	• Further data is needed to clarify the role of this rapidly evolving modality

CMRI, cardiac magnetic resonance imaging; FDG-PET, ¹⁸F-fluorodeoxyglucose positron emission tomography; IE, infective endocarditis; MDCTA, multidetector computed tomographic angiography; NVE, native valve endocarditis; PVE, prosthetic valve endocarditis; TEE, transesophageal echocardiogram; TTE, transthoracic echocardiogram.