Though transesophageal echocardiography is required in most patients suspected to have infective endocarditis because of better sensitivity, valvular vegetations can be seen on a transthoracic echocardiogram, especially when large. It is important for nephrologists to be aware of the characteristic features of these lesions as we frequently take care of patients with dialysis access infection and bacteremia. Essentially, vegetation is an infected mass usually attached to cardiac valves or implanted intracardiac materials such as pacemaker wires. Vegetations tend to be irregular in shape, mobile (independent of the valve unlike calcification) but attached to the upstream (= low-pressure) side of the valve. Fresh vegetations are usually hypoechoic or isoechoic to the myocardium whereas old lesions tend to be hyperechoic, and may be calcified. Valvular regurgitation due to destructive valve lesions is a frequent accompaniment and hence Color Doppler evaluation should always be performed. Following are two classic examples (grey scale)
Here is an example of pacemaker wire-associated endocarditis detected on transthoracic echo.