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a major diagnostic criterion. Definitions of the anatomic and metabolic features of the infective lesions can be found in the Supplementary data online, Table S5. (ii) Abnormal prosthetic or periprosthetic uptake (intense focal or heterogeneous) detected by [18F]FDG-PET/CT or WBC SPECT/CT should be considered a major criterion for PVE, irrespective of the interval from surgery (see Supplementary data online, Figure S1). Published data support that intense focal or heterogeneous patterns is associated with a final diagnosis of infection, while post-operative inflammatory changes can be persistent more than 3 months after surgery, as noted in the previous guidelines. However, these inflammatory changes can be differentiated from infection even after recent valve implantation.246 Therefore, a consensus of experts has concluded that the need for a time interval prior to investigation is questionable, but accurate imaging interpretation by proper interpretation criteria is mandatory.233,236 5.5.1.3 Minor criteria Distant IE-related lesions include all lesions that can result from embolic events and from haematogenous seeding of bacteria. These lesions can be suspected due to specific symptoms or can be incidentally detected on imaging techniques. Spondylodiscitis is the most frequent osteoarticular infective complication in patients with IE.247,248 5.5.1.4 Microbiological criteria Molecular biology (16S/18S rRNA PCR sequencing) in cardiac tissue or embolic material has increased the diagnostic performance of IE with negative blood culture. The sensitivity ranges between 41% and 96% and the specificity is very high, ranging between 90% and 100%.249 Repeat blood cultures if negative or doubtful Repeat TTE/TOE within 5–7 days PET/CT(A) to detect pocket infection +/pulmonary embolism Add minor criteria: thoracic CT to detect septic pulmonary embolism/infarction PET/CT(A) to detect lead infection (Class IIa) (Class IIb) (Class I) Suspected CIED-associated IE ESC 2023 DIAGNOSTIC CRITERIA after IE Baseline assessment and initial classification: clinical presentation + blood cultures + TTE + TOE (Class I) POSSIBLE REJECTED DEFINITE Figure 7 European Society of Cardiology 2023 algorithm for diagnosis of cardiac device-related infective endocarditis. CIED, cardiovascular implanted electronic device; CT, computed tomography; CTA, computed tomography angiography; ESC, European Society of Cardiology; IE, infective endocarditis; PET, positron emission tomography; TOE, transoesophageal echocardiography; TTE, transthoracic echocardiography; WBC SPECT, white blood cell single photon emission tomography. Downloaded from academic.oup.com/eurheartj/article/44/39/3948/7243107 by guest on 07 October 2026