Cardiac Computed Tomography in Infective Endocarditis: A Radiological Perspective on Structural Complications and Emerging Diagnostic Technologies

Background: Infective endocarditis (IE) remains a life-threatening disease associated with substantial morbidity and mortality. Transthoracic and transesophageal echocardiography are the first-line imaging modalities, but their diagnostic performance may be reduced in patients with prosthetic valves, intracardiac devices, previous cardiac surgery, extensive calcification, or suspected periannular extension. Cardiac computed tomography (CT) provides complementary high-resolution anatomical information and has gained increasing importance within contemporary multimodality diagnostic pathways. Scope: This Review critically examines the current role of cardiac CT in IE, including acquisition and reconstruction strategies, lesion-specific imaging findings, applications in native, prosthetic, transcatheter, and device-related infection, extracardiac assessment, and preoperative planning. Comparative observations regarding echocardiography and selected multimodality techniques are integrated where directly relevant. Emerging applications of spectral CT, photon-counting detector CT, deep learning reconstruction, radiomics, and artificial intelligence are appraised according to four levels of evidence: clinically validated IE applications, preliminary IE-specific evidence, indirect cardiovascular evidence, and conceptual applications. Main Findings: Cardiac CT is particularly valuable for detecting and anatomically characterizing periannular complications, including abscesses, pseudoaneurysms, fistulous tracts, inflammatory extension, and prosthetic dehiscence. Multiphase electrocardiography (ECG)-gated acquisition improves the assessment of dynamic valvular and prosthetic abnormalities. Transesophageal echocardiography remains more sensitive for small or highly mobile vegetations, leaflet perforation, regurgitant jets, and intracardiac flow abnormalities, demonstrating that the two techniques are complementary rather than interchangeable. Cardiac CT also contributes to coronary assessment, surgical planning, evaluation of previous grafts and reconstructive material, and selected extracardiac complications. Conclusions: Cardiac CT is an important component of contemporary multimodality IE assessment, but it should not be regarded as a replacement for echocardiography. Its clinical value depends on the infected substrate, suspected complication, acquisition protocol, and integration with echocardiographic, microbiological, surgical, and clinical findings. Emerging technologies may improve image quality and quantitative characterization, but most remain supported by preliminary IE-specific, indirect cardiovascular, or conceptual evidence and should not yet be considered established IE-specific diagnostic tools.