TTE has sensitivity of 50-60% for confirming endocarditis.

Negative study does not exclude. However – completely normal study has high negative predictive value.

False positives – ruptured chordae, fibroelastoma or thickened nodules can be misinterpreted for vegetations.


Similar texture to myocardium and not echo-bright – calcification may appear nodular etc.

Upstream side of valve (i.e. LA side of MV).

Can be attached to any part of valve but most commonly coaptation line.

Oscillating motion and prolapse into upstream chamber.

Lobulated shape.

Attached to prosthetic material if present.

Fungal infections often manifest as much larger vegetations.

If visualised on 2D must be measured and maximal size reported.

Also comment on mobility due to risk of embolism.

Potential risk of valve destruction and incompetence.

Large vegetations may obstruct flow and lead to stenosis.

Describe by MELTS:

  • Motion (independent of valve)
  • Effects (regurg, abscess)
  • Location (upstream, on prosthetic material)
  • Texture
  • Shape

When to request TOE:

If TTE non-confirmatory and clinical suspicion high. Negative TOE with high clinical suspicion may also warrant further assessment.

Confirmed IE on TTE – to critique lesion and assess for complications e.g. root abscess.

Prosthetic valve endo or presence of prosthetic materal e.g. pacemaker..

New complications e.g. heart block or embolic event.