Contemporary Approaches to the Use of Imaging in Infective Endocarditis

Infective endocarditis (IE) remains a complex and life-threatening condition, often posing diagnostic challenges despite advances in the field. Accurate identification of pathogens and comprehensive detection of both cardiac and extracardiac lesions are essential. Echocardiography remains the cornerstone first-line imaging modality for evaluating valve lesions and functional impairment, with its findings constituting major diagnostic criteria. However, advanced imaging techniques-including computed tomography, nuclear imaging, and magnetic resonance imaging-have become valuable tools for resolving challenging cases, confirming or ruling out the endocarditis itself and detecting distant lesions that may allow achieving a definite diagnosis. These modalities are now integrated into a multimodal imaging strategy and evidence-based diagnostic algorithms tailored to the most common clinical scenarios. Recent 2023 updates to international guidelines have refined diagnostic criteria for IE. The European Society of Cardiology Guidelines and the Duke-International Society for Cardiovascular Infectious Diseases criteria emphasize a multimodal imaging approach, assigning equal diagnostic value to evidence of IE lesions detected across various imaging modalities. This approach has broadened the diagnostic possibilities for the heterogeneous population of patients with IE, thereby improving case interpretation and clinical decision making by multidisciplinary endocarditis teams. Validation studies demonstrated improvement of the diagnostic accuracy with these updated criteria: an important advancement for this severe disease. This review summarizes current evidence-based imaging recommendations, highlighting a rational and effective multimodal imaging strategy.