Indications for Transesophageal Echocardiography in Patients with Candidemia

Risk Stratification for Transesophageal Echocardiography

The American College of Cardiology recommends that patients with candidemia who are at high risk for Candida infective endocarditis, particularly those with fungal infections, prosthetic valves, existing valvular heart disease, or persistent fever, should undergo transesophageal echocardiography (TEE) due to the high mortality rate of fungal endocarditis (36-49%) 1, 2
Patients with fungal infections, including candidemia, are explicitly identified as high-risk for complications requiring reevaluation with TTE and/or TEE, according to the American College of Cardiology 1, 2
The American College of Cardiology suggests that TEE is reasonable in patients with prosthetic heart valves and persistent fever without bacteremia or new murmur 1, 2
Patients with persistent fever despite appropriate antifungal therapy should undergo TEE, as it suggests possible endocarditis, as recommended by the American College of Cardiology 1, 2
The American College of Cardiology recommends TEE for patients with new murmur or change in clinical status, as it warrants reevaluation 1, 2
TEE is recommended for patients with intracardiac device leads, according to the American College of Cardiology 1, 2

The American College of Cardiology recommends starting with transthoracic echocardiography (TTE) in all candidemic patients, with a sensitivity of 70% for native valves but only 50% for prosthetic valves 3
The American College of Cardiology suggests proceeding directly to TEE if a prosthetic or mechanical valve is present, as TEE has a sensitivity of ~90% compared to TTE's ~50% 3, 4
TEE should be performed if TTE is nondiagnostic but clinical suspicion persists, according to the American College of Cardiology 1, 2

TEE demonstrates superior diagnostic accuracy, with a sensitivity >90% for detecting intracardiac lesions in infective endocarditis, as reported by the American College of Cardiology 5
TEE has a negative predictive value of up to 98.6%, according to the American College of Cardiology 4, 5
TEE has a specificity of 91-100% across all valve types, as reported by the American College of Cardiology 4

If initial TEE is negative but clinical suspicion persists, repeat TEE after 3-5 days, as recommended by the American College of Cardiology 5
A negative TEE never completely rules out infective endocarditis, according to the American College of Cardiology 5

TEE findings have direct mortality implications, with intracardiac abscess detected on echocardiography independently predicting both in-hospital and 1-year mortality, as reported by the American College of Cardiology 5
Valve perforation independently predicts 1-year mortality, according to the American College of Cardiology 5
Left ventricular ejection fraction <40% combined with intracardiac abscess predicts in-hospital mortality, as reported by the American College of Cardiology 5

TEE has limitations despite high sensitivity, including acoustic shadowing from prosthetic materials that can limit visualization, according to the American College of Cardiology 4
Anterior prosthetic ring abscesses may be missed, and false negatives can still occur despite 98.6% negative predictive value, as reported by the American College of Cardiology 4, 5
Cardiac CT may provide complementary information when TEE is inconclusive for prosthetic valve endocarditis, according to the American College of Cardiology 4