The CardioPhiles

TTE vs. TEE IE

TTE: Sens. 46% Spec. 95%

TEE: Sens. 93% Spec. 96%

Veg typical features:

     Gray scale & low level of reflectance

     Positioned on the upstream side of valves (i.e. atrial side of MV, ventricular side of AV)

     Lobulaed, amorphous & mobile

A negative TEE does not r/o IE Otto 2002

Major Duke Echo Criteria

     1. Mobility

     2. Echodense masses attached to valve leaflets or mural endocardium

     3. Perivalvular abscess

     4. New prosthetic valve dehiscence Kerut EK. 2nd Ed. 2004

TTE may detect vegs > 3mm TEE may detect vegs > 1mm

Vegs usually found on leading edge of valve & are often in the low pressure side of the regurgitant jet 

Calcification will restrict valve mobility whereas a veg will not

Leaflet aneurysm formation & leaflet perforation are very suggestive of IE

Prosthetic valve vegs are generally difficult to diagnose

     Mechanical valves usually involeperivalvular ring & abscess formation - Dehisced prosthetic valves may demonstrate “rocking” through cardiac cycle; more than 40% of the circunference of the ring must be involved before that’s evident 

     Bioprosthetic infection along valve ring but also leaflets themselves - Insensitive but highly specific sign of bioprosthetic valve IE is a vegetation extending past the normal extent of a fully opened valve; helps distinguish from degenerated valve leaflet

Vegetations most likely to embolize:

     >10mm; higly mobile vegs >15mm are at particularly high risk

     Attached to MV, especially ant leaflet

     Involve multiple leaflets

TV IE is often an acute process, vegetations are usually larger than L-sided vegs; pts IVDA or underlying heart disease (L-to-R shunt, valve disease)

PV IE usually occurs in the setting of Cong HD; in IVDA is much less common than TV infection

Fungal usually large vegs, frequntly emblize but less local leaflet destruction

False Positive TTE/TEE: Flail MV leaflet (If a flail leaflet & ruptured chordae are detected, it is often difficult to determine wheather infection was the cause), Lambl’s excrescences, Papillary fibroelastoma, Prosthetic valve sutures, thrombus, or pannus, Libman-Sacks endocarditis (Usually sessile with leaflet thickening w/o independent lesion motion), Nonbacterial thombotic & Marantic endocarditis; Degenerative valve changes; Acute rheumatic carditis (Multiple 3-5mm nodules w/o independent mobility; focal nodular thickening of valve tips & leaflet body); RA (Usually single nodular lesion <5mm size, spherical homogeneous); Ankylosis spondilitis (Subaortic sessile “bump”, may extend to base of ant MV leaflet); Nodules of Arantius .

Complications of IE

By definition an abscess doesn’t communicate with IV space but mycotic aneurysm does.

Abscess occurs within the native Ao annulus, usually in the region of the posterior aortic root, and occurs more commonly with aortic then mitral prosthetic valves

Abscess: echo free space

Subaortic lesion in the MAIVF (mitral-aortic intervalvular fibrosa) are better assess by TEE