**11.2. Contrast echocardiography**

Three-dimensional functionalities such as X-plane, real-time, and multibeat 3D should be routinely incorporated, especially for TEE examination of the mitral and aortic valves. Transthoracic 3D of the tricuspid valve is useful for assessing valve anatomy and pathology, particularly in patients with regurgitation associated with pacing leads [126]. For valvular complications of endocarditis, 3D zoom is preferred, providing good spatial and temporal resolution with a single-beat acquisition [123]. However, if assessing extensive perivalvular pathology or ventricular size and function, then change to a wide-angle full-volume 3D

Leading echocardiography laboratories must ensure that high standards are accomplished both for clinical practice and for scientific research. Recommendations for core laboratories, including quality control guidelines, have been published by the American Society of Echocardiography [108, 127] and European Association of Echocardiography (Cardiovascular Imaging) [128]. Periodic auditing of stored images and reports should be undertaken and reviewed by an experienced physician. Echocardiographic findings of endocarditis should undergo pathological correlation with surgery or a complimentary imaging modality, such as

For a center to develop excellence in endocarditis management, a dedicated imaging and clinical database should be established for auditing, quality control, and research purposes. Recent guidelines recommend the establishment of a specialized multidisciplinary team at centers with expertise in managing IE [109]. This approach has been demonstrated to reduce mortality by over 50% [129]. The endocarditis team should be engaged early in the manage-

The lead echocardiologist should have expertise in the field of cardiac infection and provide ongoing education to medical colleagues and sonographers alike to ensure the highest imaging standards are met. When IE is suspected on echo, expert interpretation of the findings should be communicated urgently to the treating team, especially when significant pathology is identified. The echocardiologist is also able to advise of any requirement for a supplemental procedure, such as TEE or CT, and provide recommendations with regard to appropriate

Intracardiac echocardiography (ICE) has the potential to provide better image quality than TEE due to its use of higher frequency ultrasound in close proximity to the right-sided cardiac structures. Narducci et al. [79] directly compared the two modalities, with ICE detecting more

ment of suspected IE and urgent echocardiography performed.

**11. Complimentary imaging modalities and future directions**

follow-up imaging [17, 27, 109, 130].

**11.1. Intracardiac echocardiography**

intracardiac masses than TEE (**Table 4**).

multibeat acquisition.

80 Contemporary Challenges in Endocarditis

**10. Quality control**

cardiac CT.

The application of targeted microbubbles and molecular contrast imaging offers promise as an emerging field of research. Contrast agents could be designed to tag certain cellular or molecular markers, such as inflammatory cells or ligands, enabling contrast imaging to detect the presence, location, and extent of the targeted pathology [133].
