Infective endocarditis (IE) continues to have high rates of adverse outcomes, despite recent advances in diagnosis and management. Although the use of computer tomography and nuclear imaging appears to be increasing, echocardiography, widely available in most centers, is the recommended initial modality of choice to diagnose and consequently guide the management of IE in a timely-dependent fashion. Echocardiographic imaging should be performed as soon as the IE diagnosis is suspected. Several factors may delay diagnosis, for example echocardiography findings may be negative early in the disease course. Thus, repeated echocardiography is recommended in patients with negative initial echocardiography if high suspicion for IE persists, in patients at high risk. However systematic echocardiographic screening should not be utilized as a common tool for fever, but only in the presence of a reasonable clinical suspicion of IE. It may increase the risk of false positive rates of patients requiring IE therapy or may exacerbate diagnostic uncertainty about subtle findings. Considering the complexity of the disease, the echocardiographic proper use should be increasingly time-efficient and focused on the correct identification of IE lesions and associated complications. The path to identify patients who need surgery passes through an echocardiographic skill ensuring the identification of the cardiac anatomical structures and their involvement on the destructive infective extension. We pointed out the role of echocardiography focused on the correct identification of IE distinctive lesions and the associated complications, as part of a diagnostic strategy, within an integrated multimodality imaging, managed by an “endocarditis team”.