Editorial: Evaluating imaging modalities in the diagnosis of infective endocarditis

Multidisciplinary team assessment underlined that risks of surgery were extremely high and the patient died on the same day after discharge. Zheng et al. described the case of a woman with a 7-months history of fever and persistent chest discomfort. Initial tests showed leukopenia, anemia and elevated inflammatory markers. Transthoracic echocardiogram (TTE) demonstrated numerous echogenic vegetations affixed to the anterior mitral valve, including one particularly prominent of 17x11 mm, and severe mitral insufficiency strongly suggesting fungal IE. CT scanning and abdominal ecography resulted negative for embolic lesions. Despite refusing TEE, she underwent urgent valve replacement that revealed the presence of additional small vegetations and a perforation on the aortic valve which required mechanical mitral and aortic valves were implanted. Blood cultures and intraoperative biopsies confirmed the presence of Candida guilliermondii infection, treated therefore with fluconazole therapy and, after completion, the patient remained asymptomatic and fully recovered at subsequent follow-up. Cabrucci et al. published a case of a woman who underwent transfemoral transcatheter aortic valve implantation (TAVI) that presented with fatigue, dyspnea and fever. Blood tests showed leukocytosis and elevated procalcitonin while blood cultures grew Staphylococcus aureus. TTE and TEE revealed the presence of large vegetations on the prosthetic valve, severe non-structural dysfunction, and high transvalvular gradients. Subsequent angio-CT scanning revealed thrombosis between the left coronary and non-coronary cusps of the prosthesis and splenic embolization. Antibiotic therapy was started but her condition deteriorated, prompting reconsideration of surgery despite extremely high surgical risk. Prosthetic valves were removed and replacement of the ascending aorta and valve were performed. The patient recovered well and remained event-free at 15-month follow-up. Lastly, Montarello et al. proposed a pictorial review of seven cases with the aim to explore the value of systematic cardiac CT for the diagnosis and management of IE, in particular when echocardiography is inconclusive. CT identified key findings such as vegetations on native and prosthetic valves, pseudoaneurysms, abscesses, fistulae, leaflet perforations, and septic emboli, many of which were missed or insufficiently characterized by TTE or TEE. CT proved particularly advantageous in prosthetic valve IE, where artifacts often hinder echocardiographic assessment, and in defining the extent of paravalvular disease. The authors moreover highlights how modern IE guidelines increasingly integrate multimodality imaging. In this setting, while echocardiography remains first-line for detecting vegetations and assessing valve function, CT offers superior visualization of paravalvular structures, extracardiac complications, and coronary anatomy, contributing to surgical planning and risk assessment. Limitations of this diagnostic procedure include radiation, contrast use, artefacts, and reduced utility for small vegetations. Overall, CT was endorsed as a complementary, sometimes essential, tool for achieving a definite IE diagnosis and guiding timely intervention. In conclusion, this Research Topic comprises several studies highlighting the potential applications of various imaging modalities in the diagnosis and management of IE, thereby supporting a more personalized approach to patient care.