Endocarditis vegetation is an irregular mass lesion composed of infected or sterile thrombotic material attached to heart valve leaflets. It most commonly affects the mitral and aortic valves; in intravenous drug users, tricuspid valve involvement is characteristic. Vegetations typically appear as mobile, irregular, echogenic masses attached to the atrial surface of the valve leaflet and are best visualized by transesophageal echocardiography (TEE). The modified Duke criteria represent the diagnostic standard, with major criteria including positive blood cultures and echocardiographic evidence of vegetation. Complications include septic embolization (cerebrovascular events, mycotic aneurysms, pulmonary emboli), valvular regurgitation, perivalvular abscess, and heart failure. Osler nodes (painful fingertip nodules) and Janeway lesions (painless palmar/plantar erythematous lesions) are classic clinical findings.
Age Range
20-75
Peak Age
50
Gender
Equal
Prevalence
Uncommon
The pathophysiology of endocarditis vegetations begins with fibrin and platelet deposition on damaged valvular endothelium. During bacteremia, microorganisms adhere to this thrombotic nidus, forming the infected vegetation. Vegetations grow on the low-pressure (atrial) surface of the valve leaflet because the regurgitant jet creates endothelial damage on this surface. On imaging, they appear as mobile, irregular echogenic masses; this appearance results from the fibrin-platelet matrix strongly reflecting ultrasound waves. Vegetation size directly correlates with embolic risk: vegetations >10 mm carry high embolic risk. CT and MRI demonstrate the consequences of septic emboli in target organs (brain abscess, mycotic aneurysm, splenic infarct). Perivalvular abscess development occurs when infection extends beyond the valve annulus into surrounding tissues, appearing as periannular low attenuation/signal alteration on CT/MRI.
Visualization of a mobile, irregular, echogenic mass on the atrial surface of the valve leaflet on transesophageal echocardiography is pathognomonic for endocarditis vegetation. TEE is the gold standard imaging modality with 90-95% sensitivity. Vegetation mobility, size (>10 mm = high embolic risk), and location guide treatment decisions.
Mobile, irregular, echogenic mass on valve leaflet; typically located on the atrial surface. Detected with 50-60% sensitivity by TTE and 90-95% sensitivity by TEE. Vegetations show oscillation independent of valve motion.
Report Sentence
A mobile, irregular, echogenic mass measuring ... mm is noted on the atrial surface of the valve leaflet, consistent with endocarditis vegetation.
Valvular regurgitation accompanying the vegetation is demonstrated with color Doppler. New-onset or worsening regurgitation is a Duke minor criterion for endocarditis. Jet direction and width reflect the degree of valve damage. Severe regurgitation may cause acute heart failure.
Report Sentence
Color Doppler examination reveals ... degree regurgitation at the ... valve, consistent with valve dysfunction secondary to vegetation.
Hypoechoic or anechoic space around the valve annulus indicating perivalvular abscess formation. Most commonly seen in the aortic root region. TEE has >90% sensitivity for demonstrating complicated endocarditis (abscess, fistula, pseudoaneurysm). Internal echoes within the abscess cavity reflect infected material.
Report Sentence
A hypoechoic area measuring ... mm is noted around the ... valve annulus, consistent with perivalvular abscess formation.
Low attenuation (soft tissue density) filling defect or irregular mass on valve leaflets on cardiac CT angiography. ECG-gated CT increases temporal resolution and minimizes motion artifacts. CT is complementary to echocardiography in evaluating complications such as perivalvular abscess, pseudoaneurysm, and fistula.
Report Sentence
Cardiac CT angiography demonstrates a low-attenuation filling defect/mass measuring ... mm on the ... valve leaflet, consistent with vegetation.
Hypodense collection around the valve annulus or cavitary lesion surrounded by a thickened, enhancing wall. Aortic valve perivalvular abscess most commonly occurs in the intervalvular fibrous body or membranous septum. CT demonstrates the anatomic extent of the abscess and its relationship to adjacent structures better than echocardiography. Complications such as abscess-aortic fistula or ventricular septal perforation can be assessed.
Report Sentence
A hypodense collection measuring ... mm with an enhancing wall is noted around the ... valve annulus, consistent with perivalvular abscess.
Low-to-intermediate signal mobile mass on the valve leaflet compared to hyperintense blood pool on cine SSFP sequences. Cardiac MRI uses cine imaging to assess vegetation motion in real-time. Although temporal resolution is lower than echocardiography, it serves as an alternative imaging method when TEE is contraindicated or suboptimal.
Report Sentence
Cine SSFP imaging demonstrates a low-signal mobile mass on the ... valve leaflet relative to the blood pool, consistent with vegetation.
Ring-like enhancement pattern around the valve annulus on late gadolinium enhancement (LGE) sequences indicates perivalvular abscess or inflammatory changes. Granulation tissue in the abscess wall retains gadolinium and appears as a hyperintense rim. The center of the abscess cavity remains low signal intensity (necrotic/liquefied material). MRI is superior to CT in assessing extension of the abscess into the myocardium and conduction system.
Report Sentence
LGE imaging demonstrates ring-like enhancement around the ... valve annulus with central low signal area, consistent with perivalvular abscess.
Increased FDG uptake in the infected valve region on 18F-FDG PET/CT. Diagnostic value is high in prosthetic valve endocarditis (sensitivity 73-97%, specificity 80-100%). Sensitivity is lower in native valve endocarditis. Accepted as a major diagnostic criterion for prosthetic valve endocarditis in 2023 ESC guidelines. Provides additional value in detecting perivalvular abscess, septic embolic foci, and metastatic infection sites.
Report Sentence
18F-FDG PET/CT demonstrates focally increased FDG uptake in the ... valve/prosthetic valve region (SUVmax: ...), consistent with active infectious/inflammatory process.
Criteria
Vegetation on natural valve leaflet; most commonly involves mitral (40-45%) and aortic (35-40%) valves. Staphylococcus aureus and Streptococcus viridans are the most common causative organisms.
Distinct Features
Vegetations grow on the atrial surface of the leaflet at the jet lesion site. A2-P2 segments of the mitral valve and noncoronary/right coronary cusps of the aortic valve are the most commonly involved regions. Valve perforation and severe regurgitation may develop as complications.
Criteria
Vegetation on or around mechanical or bioprosthetic valve. Classified as early (<60 days postoperative) and late (>60 days). Early form is commonly caused by coagulase-negative staphylococci; late form by S. aureus and streptococci.
Distinct Features
Acoustic shadowing from prosthetic material on echocardiography makes diagnosis challenging; TEE is mandatory. CT and PET/CT are complementary modalities. Perivalvular abscess and dehiscence (valve separation) are much more common than in native valve endocarditis. Focal FDG uptake around the prosthesis on PET/CT has diagnostic value.
Criteria
Tricuspid (most common) or pulmonary valve involvement. Accounts for 5-10% of all endocarditis. Intravenous drug users, central venous catheter carriers, and patients with intracardiac devices (pacemaker/ICD) are at risk. S. aureus is the dominant pathogen.
Distinct Features
Pulmonary septic emboli develop instead of systemic emboli: multiple, peripheral, cavitary nodules and wedge-shaped consolidations (Hampton hump) on lung CT. Tricuspid vegetations can often be large (>20 mm), yet surgical indication remains controversial. Prognosis is generally better than left-sided endocarditis.
Criteria
Sterile fibrin-platelet vegetations; typically located on the coaptation line of mitral and aortic valves. Associated with advanced malignancy (especially pancreatic and ovarian adenocarcinoma), SLE (Libman-Sacks endocarditis), antiphospholipid syndrome, and DIC.
Distinct Features
Vegetations are typically small (<5 mm), sessile (minimally mobile), and broad-based; may have more regular contours than infective vegetations. Blood cultures are negative. Risk of systemic embolization (especially cerebrovascular) is high. Echocardiographic differentiation from infective vegetations can be difficult; clinical context (malignancy, autoimmune disease) guides diagnosis.
Distinguishing Feature
Papillary fibroelastoma is a small (<15 mm), round, homogeneous, well-defined, pedunculated mass typically located on the ventricular surface of the aortic valve. Vegetations have irregular contours, are located on the atrial surface of the leaflet, and are clinically associated with fever/positive blood cultures.
Distinguishing Feature
Lambl excrescences are very small (<3 mm), thin, strand-like, mobile structures at the valve coaptation line and are usually incidentally detected. Vegetations are larger, irregular, and accompanied by clinical signs of infection. Lambl excrescences are part of degenerative changes in elderly adults.
Distinguishing Feature
Myxoma is typically located in the left atrium at the fossa ovalis region of the interatrial septum; it is much larger than vegetations (typically 3-6 cm). It is a lobulated, gelatinous mass attached to the septum by a stalk. Vegetations are attached to valve leaflets and accompanied by signs of infection.
Distinguishing Feature
Cardiac thrombus typically is located on the chamber wall adjacent to akinetic/dyskinetic myocardial segments (left ventricular apex, left atrial appendage), not on valve leaflets. On MRI LGE, thrombus does not enhance (avascular), while vegetation may show peripheral enhancement. Clinically, thrombus is not associated with fever and positive blood cultures.
Distinguishing Feature
Degenerative valve calcification appears as high-density (>130 HU), immobile foci localized to the fibrous/basal regions of valve leaflets on CT. Vegetations are soft tissue density, mobile, and irregularly contoured. Calcification may create hemodynamic stenosis; vegetation presents with signs of infection.
Urgency
emergentManagement
medicalBiopsy
Not NeededFollow-up
Tedavi süresince seri TÖE (başlangıç, 7-10. gün, antibiyotik bitiminde), cerrahi sonrası erken ve 3-6. ayda kontrol ekokardiyografi / Serial TEE during treatment (baseline, day 7-10, end of antibiotics), early and 3-6 month follow-up echocardiography post-surgeryInfective endocarditis is an infectious disease requiring emergency medical intervention with high mortality (15-30%). Treatment requires prolonged intravenous antibiotic therapy (4-6 weeks). Surgical indications include: heart failure from severe valvular regurgitation, uncontrolled infection (perivalvular abscess, persistent bacteremia), and high embolic risk (>10 mm mobile vegetation, especially after early embolic event). Management should be by a multidisciplinary endocarditis team (cardiology, infectious diseases, cardiac surgery, neurology). Prophylaxis is recommended for high-risk patients (prosthetic valve, prior endocarditis, cyanotic congenital heart disease) before dental procedures.
Infective endocarditis is a serious infection with nearly 100% mortality if untreated. Prolonged IV antibiotic therapy (4-6 weeks) is required. Surgical indications include: heart failure, uncontrolled infection, high embolization risk (>10 mm mobile vegetation), periannular abscess, and prosthetic valve endocarditis. Septic emboli can spread to brain, spleen, kidney, and lungs (in right-sided endocarditis). TEE is markedly superior to TTE (sensitivity 90-100% vs 60-70%).