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Recent evolution of cardiac computed tomography (CT) provides useful information about valvular and perivalvular structures. We compared the diagnostic performance of CT and transesophageal echocardiography (TEE) with applications of 3-dimensional reconstruction in detecting vegetation and intracardiac complications in patients with infective endocarditis (IE).Seventy-five patients (53 men; age, 58±15 years) with definite IE who underwent TEE and CT with 3-dimensional reconstruction within 3 days were analyzed. The diagnostic performances of the 2 modalities for vegetation and IE-related intracardiac complications (valve perforation, valve aneurysm, perivalvular abscess, pseudoaneurysm, fistula, and prosthetic valve dehiscence) were compared. The detection rate of vegetation in TEE and CT was 97.3% and 72.0%, respectively. The maximum sizes of vegetation identified by TEE and CT were well correlated (r=0.593; P<0.001), especially in patients with large vegetation (≥10 mm), suggestive of a high risk of systemic embolism (r=0.608; P<0.001). However, small vegetation (<10 mm) was underdiagnosed by CT (52.8%) compared with TEE (94.4%), and the sizes of the 2 modalities were poorly correlated (r=0.187; P=0.445). Both modalities showed fair diagnostic performance for detecting IE-related intracardiac complications with excellent agreement. TEE was more useful for diagnosing valve perforation and intracardiac fistula, whereas CT was better for diagnosing perivalvular abscess.Cardiac CT shows a comparable diagnostic performance with TEE for large vegetation and several IE-related complications. TEE is better for detecting small vegetation, valve perforation, and intracardiac fistula, whereas CT is more useful for detecting perivalvular abscess and coronary artery disease.