Risk of Embolism and Death in Infective Endocarditis: Prognostic Value of Echocardiography

TLDR

In infective endocarditis, embolic events and death remain common, but predictors of these complications are inconsistent and the role of echocardiography in risk stratification is poorly defined. This study prospectively evaluated clinical, microbiological, and echocardiographic variables as predictors of embolic events and one‑year mortality in 384 European patients with definite infective endocarditis. All patients underwent transesophageal echocardiography, and the resulting measurements were combined with clinical and microbiological data for analysis. Embolic events occurred in 34.1% of patients, with Staphylococcus aureus, Streptococcus bovis, vegetation length >10 mm, and high mobility predicting emboli, while vegetation length >15 mm independently predicted 20.6% one‑year mortality, demonstrating that echocardiographic assessment identifies high‑risk patients.

Abstract

The incidence of embolic events (EE) and death is still high in patients with infective endocarditis (IE), and data about predictors of these 2 major complications are conflicting. Moreover, the exact role of echocardiography in risk stratification is not well defined. In a multicenter prospective European study, including 384 consecutive patients (aged 57+/-17 years) with definite IE according to Duke University criteria, we tested clinical, microbiological, and echocardiographic data as potential predictors of EE and 1-year mortality. Transesophageal echocardiography was performed in all patients. Embolism occurred before or after IE diagnosis (total-EE) in 131 patients (34.1%) and after initiation of antibiotic therapy (new-EE) in 28 patients (7.3%). Staphylococcus aureus and Streptococcus bovis were independently associated with total-EE, whereas vegetation length >10 mm and severe vegetation mobility were predictors of new-EE, even after adjustment for S aureus and S bovis. One-year mortality was 20.6%. In multivariable analysis, independently of the other predictors of death (age, female sex, creatinine serum >2 mg/L, moderate or severe congestive heart failure, and S aureus) and comorbidity, vegetation length >15 mm was a predictor of 1-year mortality (adjusted relative risk=1.8; 95% CI, 1.10 to 2.82; P=0.02). In IE, vegetation length is a strong predictor of new-EE and mortality. In combination with clinical and microbiological findings, echocardiography may identify high-risk patients who will need a more aggressive therapeutic strategy.