Transesophageal vs. transthoracic echocardiography for infective endocarditis: a systematic review and meta-analysis

This meta-analysis aims to systematically evaluate the diagnostic accuracy of transesophageal echocardiography (TEE) vs. transthoracic echocardiography (TTE) in detecting infective endocarditis (IE).

A comprehensive computerized search was performed in PubMed, Embase, Web of Science, and Cochrane Library databases to identify relevant English-language diagnostic trials or cohort studies published from inception to September 2025. Two independent researchers conducted literature screening, data extraction, and quality assessment using the Newcastle-Ottawa Scale. Diagnostic accuracy data were extracted or calculated, and pooled sensitivity, specificity, and their 95% confidence intervals (CIs) were determined. A summary receiver operating characteristic (SROC) curve was constructed. Statistical analyses were performed using RevMan 5.3 and Stata 18.0 and related software. Heterogeneity was assessed using the I² statistic, and publication bias was evaluated using Deeks' funnel plot asymmetry test.

A total of 13 studies involving 2,765 suspected patients with IE were finally included. A meta-analysis demonstrated that, using TEE as the reference, the pooled sensitivity of TTE was 0.72 (95% CI: 0.55-0.84), and the pooled specificity was 0.72 (95% CI: 0.55-0.85), with significant heterogeneity (sensitivity I²  = 95.96%, specificity I²  = 98.73%). The area under the SROC curve was 0.78 (95% CI: 0.74-0.82), indicating moderate diagnostic performance. Publication bias was detected (P = 0.04). Sensitivity analyses confirmed the overall stability of the results, although heterogeneity sources were identified. Subgroup analyses revealed statistically significant heterogeneity in sensitivity among different TTE subgroups (P = 0.001), while no significant heterogeneity was observed in specificity subgroups.

TEE remains superior in IE diagnosis. For patients with high clinical suspicion but negative or inconclusive TTE findings, additional TEE examination is recommended to improve diagnostic accuracy and support clinical decision-making.