Echocardiography (transthoracic or transesophageal) is the principal preoperative diagnostic examination. It shows new valvular regurgitation and/or identifies typical valvular lesions such as vegetations, leaflet perforation or abscess, annular abscess, and new partial dehiscence of prosthetic valve. Transthoracic echocardiography has an excellent specificity for vegetation. Patients at risk of perivalvular extension or prosthetic valve endocarditis should undergo trans-esophageal echocardiography (TEE). TEE has a significantly higher sensitivity (76% to 100%) and specificity (94%) than TTE for perivalvular infection.
Carpentier's functional classification can be used to describe the functional type of mitral regurgitation. This functional classification determines valvular dysfunction based on an assessment of the amplitude of anterior and posterior leaflet motion during systole and diastole.
Type I mitral regurgitation
Type III mitral regurgitation
Type III dysfunction is occasionally seen in patients with healed endocarditis. In this setting, valvular vegetations and leaflet abscesses are gradually replaced by calcification and leaflet thickening due to fibrotic healing process. The retraction of the posterior leaflet and its adhesion to the ventricular wall is a well-described lesion. These chronic valvular lesions induce type IIIa functional mitral regurgitation. Annular dilatation is a secondary associated lesion, often seen, in these patients.
Di Salvo G, Habib G, Pergola V, et al. Echocardiography predicts embolic events in infective endocarditis. J Am Coll Cardiol 2001; 37:1069-1076
Senni M, Merlo M, Sangiorgi G, et al. Mitral valve repair and transesophageal echocardiographic findings in a high-risk subgroup of patients with active, acute infective endocarditis. J Heart Valve Dis 2001;10:72
Zoghbi WA, Enriquez-Sarano M, Foster E, et al. Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. J Am Soc Echocardiogr 2003;16(7):777-802.
Douglas PS, Khandheria B, Stainback RF, et al. ACCF/ASE/ACEP/ASNC/SCAI/SCCT/SCMR 2007 appropriateness criteria for transthoracic and transesophageal echocardiography: a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group, American Society of Echocardiography, American College of Emergency Physicians, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and the Society for Cardiovascular Magnetic Resonance endorsed by the American College of Chest Physicians and the Society of Critical Care Medicine. JACC 2007;50(2):187-204.