Right-Sided Endocarditis: To TEE or Not to TEE?

Abstract

Transesophageal echocardiography has been shown to be superior to transthoracic imaging in the detection of left-sided vegetations. However, its value to identify vegetations located elsewhere has not been established. This study was conducted to determine the usefulness of transesophageal echocardiography compared to transthoracic echocardiography in the assessment of patients with the suspicion of right-sided endocarditis. Transthoracic and transesophageal echocardiography were performed in 72 patients hospitalized for suspected right-sided endocarditis (62 were intravenous drug abusers and 10 had a permanent pacemaker). Vegetations were found in 32 (52%) with both techniques. There were 29 vegetations attached to the tricuspid valve, 3 to the pulmonic valve (1 was missed with transesophageal echocardiography and another with the transthoracic exam) and 1 to the eustachian valve. Pacemaker lead vegetations were echocardiographically visualized in 7 patients. Five of them had surgical confirmation. Transthoracic echocardiography detected only 2 patients with pacemaker lead vegetations whereas transesophageal echocardiography identified all 7 patients. Transesophageal echocardiography adds no diagnostic information to the transthoracic exam in the majority of intravenous drug abusers suspected of having right-sided endocarditis and it should not be performed as a routine examination. On the other hand, transthoracic echocardiography is a very limited technique for the detection of pacemaker lead vegetations and transesophageal echocardiography should be mandatory in most patients with a permanent pacemaker and clinical suspicion of an infected transvenous pacemaker.