Diagnosing infective endocarditis (IE) in older adults remains challenging. We aimed to assess the diagnostic contribution of echocardiography in geriatric patients with suspected IE.

We conducted a retrospective multicenter cohort study in three university hospitals between May 2016 and April 2021. All consecutive episodes of suspected IE discussed by a multidisciplinary endocarditis team were included. Final team adjudication served as the reference standard. Duke classification was assessed before and after transthoracic (TTE) and/or transesophageal echocardiography (TEE). Patients were compared according to age (< 75 versus ≥ 75 years).

A total of 184 suspected IE episodes (181 patients) were analyzed; median age was 74  years, and 49% were aged ≥ 75 years. Older patients had a higher Charlson comorbidity index (7.5 vs 4.5) and a higher 12-month mortality rate (37% vs 26% overall). TTE was performed in 96% of cases, whereas TEE was performed in only 38%, significantly less frequently in patients ≥ 75  years (23% vs 51%) and after a longer time (10.3 vs 5.6 days). Echocardiography modified Duke classification in 30% of cases overall, including 24% in patients ≥ 75  years. The proportion of definite IE increased from 8% before echocardiography to 33% after imaging, and from 9% to 28% in older patients. Echocardiography provided a major Duke criterion in 33% of cases, while findings were inconclusive in 25%. Neurological disorders and biological prosthetic valves were independently associated with echocardiographic diagnosis of IE.

Despite underuse and delayed TEE, echocardiography improved diagnostic classification.