Clinical Research and Treatment of Endocarditis

Dear Colleagues,

Infective endocarditis (IE) is a serious, progressive and fatal disease with an estimated annual incidence of 3–10 cases per 100,000 person-years. The in-hospital mortality is estimated around 20%, increasing to 25–30% at 6 months. Aggressive medical therapy and early surgical intervention confer a mortality benefit. Surgery is undertaken in 40–70% of patients with IE, with three principal indications: valve dysfunction leading to heart failure, uncontrolled infection, and prevention of embolism. Perivalvular complications, including abscesses, pseudo aneurysms and fistulae, considered as a complex manifestation, are reported in up to 37% of IE cases. These cases are manifested with poor biological condition, present surgical challenges and associated with increased morbidity and mortality rate. Late diagnosis is commonly associated with advanced presentation of IE. Therefore, a great effort should be done by primary physician and internist in order to diagnose these patients earlier.

The diagnosis of IE is challenging and is based on imaging, microbiological results and clinical criteria. Because of the challenging diagnosis and the complexity of the disease, a multidisciplinary approach has been established, termed Endocarditis Team (ET). However, contradictory reports exist regarding the yield of the multidisciplinary endocarditis team and its impact on timing for surgical intervention, complication rate and outcome. In addition to the valuable discussion of the ET about a specific patient, it may be important to establish an “education program” to the community which may promote earlier diagnosis and treatment.

The use of prosthetic heart valves in patients with valvular heart disease is increasing worldwide. Mechanical heart valves are often used in younger patients whereas more and more older patients usually receive biological or transcatheter aortic valve implantation (TAVI) in a native valve or in previous implanted prosthetic biological valve, i.e., valve in valve (VIV). One to six percent of all patients with heart valve prostheses are diagnosed with prosthetic valve endocarditis (PVE), and over 20% of all cases of infective endocarditis (IE) are classified as PVE. In‐hospital mortality among patients with PVE is significantly higher than in those diagnosed with native valve endocarditis. Therefore, a specific consideration should be applied for patients diagnosed with PVE. This topic should be elaborated.

Neurological complications occur in about one-fourth of patients with infective endocarditis. A discussion is required for the usefulness of systematic brain imaging for asymptomatic patients and the preferred treatment for patients with silent brain lesions. Additionally, the timing of intervention for patients with acute septic emboli and mycotic aneurysms, is still debatable and should be addressed.

Nonbacterial thrombotic endocarditis (NBTE), or marantic endocarditis, refers to a spectrum of lesions ranging from microscopic aggregates of platelets to large vegetation on previously undamaged heart valves in the absence of a bloodstream bacterial infection. The approach for this type of endocarditis should be better elucidated, in the aspects of diagnosis, medical treatment, indication for intervention and the operative outcomes.

I hope that this issue will contribute to better understanding of the above topics and other challenges related to Endocarditis.

Dr. Ram Sharony
Guest Editor

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• infective endocarditis
• endocarditis
• valvular heart disease
• perivalvular complications
• transcatheter aortic valve implantation