A multimodality imaging approach to the diagnosis of infective endocarditis: incremental value of combining modalities.

Infective endocarditis is a complex disease leading to significant morbidity and mortality. The in-hospital mortality has remained at 15-30% despite significant advances in cardiac imaging over the past two decades. Prevention, timely diagnosis, and prompt treatment can minimise adverse sequelae. The key to prevention lies in patient and clinician education. Traditionally the diagnosis has relied on the modified Duke criteria which have a sensitivity of 80%. The limitations of the modified Duke criteria are widely acknowledged, particularly where prosthetic material is present (i.e. in prosthetic valve replacements, intracardiac devices, aortic grafts and in congenital heart disease) and visibility with echocardiography alone may be poor. Advancements in multimodality imaging techniques in recent years offer additional information to improve the diagnostic process and optimise patient care. Multimodality imaging in the diagnostic work-up for suspected endocarditis now forms part of the major society guidelines. We present a case series and review of the literature on the use of multimodality cardiac imaging in the diagnosis of infective endocarditis with specific reference to transthoracic and transoesophageal echocardiography, cardiac computerised tomography (CT), cardiac positron emission tomography (PET) and cardiac magnetic resonance imaging (MRI) to illustrate the complimentary role of each modality.