Table 2.

Imaging modalities and infective endocarditis guidelines.

Imaging Modality	2015 European Society of Cardiology Guidelines for the Management of Infective Endocarditis	2020 American College of Cardiology/American Heart Association Guidelines for the Management of Patients with Valvular Heart Disease
TTE	• TTE is recommended as the first line imaging modality in suspected IE (class I, level of evidence B) • Repeat TTE and/or TEE within 5–7 days is recommended in case of initially negative examination when clinical suspicion of IE remains high (class I, level of evidence B)	• In patients with suspected IE, TTE is recommended to identify vegetations, characterize the hemodynamic severity of valvular lesions, assess ventricular function and pulmonary pressures, and detect complications (class I, level of evidence B-NR)
TEE	• TEE is recommended in all patients with a clinical suspicion of IE and a negative or non-diagnostic TTE (class I, level of evidence B) • TEE should be considered in patients with suspected IE, even in cases with positive TTE, except in isolated right-sided NVE with good quality TTE examination and unequivocal echocardiographic findings (class IIa, level of evidence C)	• In all patients with known or suspected IE and non-diagnostic TTE results, when complications have developed or are clinically suspected or when intracardiac device leads are present, TEE is recommended (class I, level of evidence B-NR) • In patients with a prosthetic valve in the presence of persistent fever without bacteremia or a new murmur, a TEE is reasonable to aid in the diagnosis of IE (class IIa, level of evidence B-NR)
Leukocyte Scintigraphy	• Leukocyte scintigraphy should be preferred in situations that require increased specificity given the modality is more specific for the detection of IE and infectious foci than FDG-PET	• No specific recommendation
FDG-PET	• Advantages of FDG-PET include reducing the rate of misdiagnosed IE by reducing those classified as possible IE via the Duke criteria and detection of metastatic and peripheral infections or embolic events • Limitations to use include localization of cerebral septic emboli due to high physiologic uptake in the brain, and low spatial resolution of current PET/CT scanners • Caution should be used when interpreting patients who have undergone recent CT surgery	• In patients classified by Modified Duke Criteria as having “possible IE,” FDG-PET/CT is reasonable as adjunct diagnostic imaging (class IIa, level of evidence B-NR)
MDCTA	• For the evaluation of PVE MDCTA may perform similarly or even superiorly to echocardiography when it comes to the detection of prosthesis associated dehiscence, vegetations, abscesses, and pseudoaneurysms. However, due to a lack of large comparative studies between the two echocardiography should always be performed first	• In patients in whom the anatomy cannot be clearly delineated by echocardiography in the setting of suspected paravalvular infections, CT imaging is reasonable (class IIa, level of evidence B-NR)
CMRI	• Myocarditis and myocardial involvement may be best assessed using CMRI and TTE	• No specific recommendation

Recommendations are quoted from the respective guidelines or summarized as appropriate. 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.