Clinical predictors of early outcomes in infective endocarditis: reassessing surgical risk

Background

Infective endocarditis (IE) remains a life-threatening condition with in-hospital mortality rates of 13-26%. Early identification of patients at higher risk of adverse outcomes is crucial to guide clinical and surgical decision-making.

Purpose

To identify independent predictors of in-hospital mortality in patients with IE managed in a real-world contemporary setting, and to evaluate the utility of EuroSCORE II for early risk stratification and surgical decision-making during the acute phase of the disease.

Methods

We conducted a retrospective study at a single tertiary center including all patients diagnosed with IE between January 2017 and December 2024. Mean follow-up was 20 ± 26 months. Surgical risk was stratified using EuroSCORE II with a 5% cut-off. The primary outcome was in-hospital mortality.

Results

Eighty-seven patients were included (mean age 62 ± 16 years; 69% male). Low surgical risk (EuroSCORE <5%) was present in 52 patients (60%), and high surgical risk (EuroSCORE ≥5%) in 35 (40%). As expected, high-risk patients were older (70 ± 12 vs 57 ± 23 years, p<0.001) and more frequently had previous cardiac surgery (45.7% vs 3.8%, p<0.001). Prosthetic aortic valve endocarditis was significantly more common in the high-risk group (34.3% vs 0%, p<0.001). These patients also more frequently developed heart failure (90.9% vs 29.2%, p<0.001) and perivalvular abscess or fistula (38.2% vs 5.4%, p=0.021).

In multivariate analysis, independent predictors of in-hospital mortality were age (OR 1.07; 95% CI: 1.01–1.14; p=0.031) and hemodynamic instability with shock (OR 15.33; 95% CI: 2.51–93.61; p=0.003). Surgical intervention was protective (OR 0.08; 95% CI: 0.01–0.51; p=0.008). EuroSCORE ≥5% was not associated with in-hospital mortality (OR 1.47; 95% CI: 0.36–5.98; p=0.588), although it predicted mid- to long-term mortality (HR 2.49; 95% CI: 1.11–5.62; p=0.028). All patients requiring continuous renal replacement therapy died during hospitalization, preventing comparative statistical analysis.

Conclusions

Older patients and those presenting with shock represent a high-risk subgroup requiring urgent multidisciplinary evaluation and prompt surgical decision. Surgical intervention appears to confer a survival benefit even among patients with elevated predicted surgical risk. The absence of an association between EuroSCORE II and in-hospital mortality suggests that this tool is limited for short-term risk prediction in IE, and that clinical and infection-related factors should carry more weight than conventional surgical-risk scores when determining early operative strategies in this setting.Baseline characteristics by EuroSCOREFor image description, please refer to the figure legend and surrounding text.