Imaging recommendation · Cardiac

Suspected infective endocarditis

Q: What's the alternative imaging for suspected infective endocarditis when suspected prosthetic valve or device infection?

NM — TEE + FDG-PET / CT (or radiolabeled WBC scan) (iv contrast).

Q: What's the alternative imaging for suspected infective endocarditis when suspected septic emboli to brain or solid organs?

MRI — CT or MRI brain + CT chest/abdomen/pelvis (iv contrast).

Recommended: TTE first; TEE if TTE negative and clinical suspicion remains is the preferred imaging study for suspected infective endocarditis. Apply Duke criteria.

Recommended study

TTE first; TEE if TTE negative and clinical suspicion remains

US No contrast Preferred Cardiac EmergencyAcute inpatient Reviewed 2026-05

Apply Duke criteria. TEE for prosthetic valves, complications, and definitive imaging.

If the default doesn't apply

Suspected prosthetic valve or device infection

NM TEE + FDG-PET / CT (or radiolabeled WBC scan) IV contrast

Suspected septic emboli to brain or solid organs

MRI CT or MRI brain + CT chest/abdomen/pelvis IV contrast

Watch-outs

Persistent bacteremia + negative TTE

Do not stop here — proceed to TEE; TTE sensitivity is only ~70% for native valve IE.

Stroke complication

Embolic stroke in IE alters surgical timing decisions — get brain MRI / CT.

Pearls

Modified Duke criteria: major (echo, blood culture, lesion) + minor criteria → definite / possible / rejected IE.
Most common organisms: Staph aureus, viridans Strep, Enterococcus, HACEK.
Echo-negative IE: consider Bartonella, Coxiella, Brucella, fungal — needs serology + PCR.