The relative value of TEE versus TTE in establishing the diagnosis of IE depends on the clinical pretest probability of IE. In patients with a low pre-test probability, in whom there are few minor and often no major clinical features of IE, TTE is generally adequate and TEE seldom gives additional information [58]. The exceptions may be patients with high-risk features and in whom TTE is known to have a low sensitivity for detecting evidence of IE (Table 7.1). Patients with prosthetic valves and technically inadequate TTE images are one example. In patients with an intermediate pre-test probability of IE, TEE often adds diagnostic information even when TTE image quality is high. These patients are frequently categorized to have possible IE based on clinical and TTE findings alone. In many of these patients diagnostic certainty can be increased with TEE, and IE can either be excluded or confirmed with obvious implications for clinical management [59,60]. TEE is especially important in patients suspected to have culture-negative IE, because many of these patients would be classified as possible endocarditis based on TTE findings, but with the TEE findings about 25% of these patients can be diagnosed to have definite endocarditis [61]. In patients with a high probability of IE, TEE is not needed for diagnosis but may be required to provide additional information to evaluate prognosis and to guide management. It may be more cost effective to perform TEE without TTE in patients with intermediate or high probability of IE, but this approach has not been properly evaluated in a clinical trial. In patients with suspected IE our practice is to always proceed first with TTE and to add TEE in specific groups of patients. This approach allows a goal-oriented TEE based on TTE findings and limits the risks of TEE to those patients who would benefit from the procedure.

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