Multimodality cardiac imaging and management of infective endocarditis: a review

Infective endocarditis (IE) remains a challenging diagnosis, particularly in patients with prosthetic valves, cardiac implantable electronic devices (CIEDs), or nonspecific presentations. With rising rates of healthcare-associated and device-related infections, the need for earlier and more reliable diagnosis has become increasingly important. Multimodality imaging now plays a central role in confirming IE, identifying complications, and guiding management. Echocardiography is the initial test of choice, with transesophageal echocardiography (TEE) offering better sensitivity for vegetations, leaflet perforation, and periannular extension, though its limitations in prosthetic valve endocarditis (PVE) have led to greater reliance on other modalities. Cardiac computed tomography (CT) provides detailed anatomical information that can reveal abscesses, pseudoaneurysms, and prosthetic dehiscence, and is frequently used for surgical planning. Functional imaging with 18F-fluorodeoxyglucose positron emission tomography/CT (FDG-PET/CT) and white blood cell single-photon emission CT/CT (WBC-SPECT/CT) improves diagnostic accuracy in PVE and CIED infections while also detecting systemic embolic events. Brain magnetic resonance imaging (MRI) has become an important tool to uncover neurologic complications, including silent emboli and mycotic aneurysms. This review summarizes the strengths and limitations of each modality, outlines a stepwise approach to imaging decisions, and considers how findings should be incorporated into overall clinical care. This review also highlights surgical indications, evolving antimicrobial strategies, and the future role of standardized imaging protocols. Taken together, thoughtful use of multimodality imaging is critical to improving outcomes in patients with suspected or confirmed IE.