A large multicenter prospective cohort study of patients
with IE found in-hospital mortality rates of 18%
[3]. Due to the high mortality risk, early recognition and
diagnosis are essential for optimal treatment of IE. Given
that TTE is non-invasive, has no major safety issues, and
can be obtained easily, it is the current standard initial
imaging test for the evaluation of IE. In comparison,
TEE is an invasive test with a low, but defined, risk of
complications. In addition, TEE can be extremely challenging
to obtain in the ED. For these reasons, mostclinicians will begin the evaluation of IE with a TTE,
even with the knowledge that this test is less sensitive
than TEE for the diagnosis of IE [4]. Studies have
suggested that probe distance and scanning through the
lung are responsible for the relatively poorer valvular
imaging by TTE. Vegetation size may also affect TTE
sensitivity. Directly comparing TTE and TEE, Erbel et al.
found only 25% of vegetations