TOE in Prosthetic Valve Endocarditis — EECC MCQ

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EasyCardiac ImagingTOE in Prosthetic Valve EndocarditisEECC

A 70-year-old woman with a prosthetic mitral valve and new-onset fever presents with possible infective endocarditis. Transthoracic echocardiography is non-diagnostic due to prosthetic valve artefact. What is the most appropriate next imaging step?

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Correct answer: C — Transoesophageal echocardiography (TOE)

TOE is the imaging modality of choice when TTE is non-diagnostic in suspected prosthetic valve endocarditis (Class I recommendation). TOE has significantly higher sensitivity than TTE for detecting vegetations, abscesses, and dehiscence on prosthetic valves (sensitivity ~90% vs ~50% for TTE). The 2023 ESC IE Guidelines recommend TOE as a first-line investigation in all suspected prosthetic valve endocarditis due to the limitations of TTE with prosthetic material. FDG-PET/CT is a valuable complementary modality (particularly for perivalvular infection and embolic events) but is second-line after TOE, not a replacement for it. A negative TOE does not exclude IE and should be repeated in 5-7 days if clinical suspicion remains high.

Reference: ESC (2023): Guidelines on Infective Endocarditis