Guidelines and Expert Consensus Documents summarize and evaluate all currently available evidence on a particular issue with the aim of assisting physicians in selecting the best management strategy for an individual patient suffering from a given condition, taking into account the impact on outcome, as well as the risk/benefit ratio of particular diagnostic or therapeutic means. Guidelines are no substitutes for textbooks. The legal implications of medical guidelines have been discussed previously.

Recent studies have shown that the annual incidence of infective endocarditis (IE) is stable between 15 and 60 cases per million.^1-4 However, since the first modern clinical description of IE by Osler,⁵ the profile of the disease has continuously evolved. This fact was highlighted in different epidemiological studies,^6,7 including a French survey of IE performed in 1991, in which the main results, compared with a similar study conducted in 1983,⁸ showed (1) stable annual incidence at 24 cases per million; (2) increased age of onset; (3) decreasing proportion of IE on abnormal native valve, compensated by an increased proportion of prosthetic valve IE and native valve IE in patients with previously unrecognized predisposing conditions; and (4) a changing microbiologic profile, with an increased proportion of group D streptococci and staphylococci.^1,9

Background. Observational studies showed that the profile of infective endocarditis (IE) significantly changed over the past decades. However, most studies involved referral centers. We conducted a population-based study to control for this referral bias. The objective was to update the description of characteristics of IE in France and to compare the profile of community-acquired versus healthcare-associated IE. Methods. A prospective population-based observational study conducted in all medical facilities from 7 French regions (32% of French individuals aged ≥18 years) identified 497 adults with Duke-Li–definite IE who were first admitted to the hospital in 2008. Main measures included age-standardized and sex-standardized incidence of IE and multivariate Cox regression analysis for risk factors of in-hospital death. Results. The age-standardized and sex-standardized annual incidence of IE was 33.8 (95% confidence interval [CI], 30.8–36.9) cases per million inhabitants. The incidence was highest in men aged 75–79 years. A majority of patients had no previously known heart disease. Staphylococci were the most common causal agents, accounting for 36.2% of cases (Staphylococcus aureus, 26.6%; coagulase-negative staphylococci, 9.7%). Healthcare-associated IE represented 26.7% of all cases and exhibited a clinical pattern significantly different from that of community-acquired IE. S. aureus as the causal agent of IE was the most important factor associated with in-hospital death in community-acquired IE (hazard ratio [HR], 2.82 [95% CI, 1.72–4.61]) and the single factor in healthcare-associated IE (HR, 2.54 [95% CI, 1.33–4.85]). Conclusions. S. aureus became both the leading cause and the most important prognostic factor of IE, and healthcare-associated IE appeared as a major subgroup of the disease.

Heart valve replacement surgery is performed in more than 150 000 patients per year in the United States and Europe,^1,2 and the number of prosthetic valve implantations continues to increase.³ Infection of a heart valve prosthesis, or prosthetic valve endocarditis (PVE), is an uncommon but potentially lethal complication of heart valve replacement surgery. Despite advances in its diagnosis and treatment, PVE is associated with substantial morbidity and mortality.^4-8 Prosthetic valve endocarditis has been estimated to occur at a rate of 0.3% to 1% per patient-year and to account for 1% to 5% of all cases of infective endocarditis (IE).^9-12

Aims : Isolated tricuspid valve surgery (ITVS) is considered to be a high-risk procedure, but in-hospital mortality is markedly variable. This study sought to develop a dedicated risk score model to predict the outcome of patients after ITVS for severe tricuspid regurgitation (TR). Methods and results : All consecutive adult patients who underwent ITVS for severe non-congenital TR at 12 French centres between 2007 and 2017 were included. We identified 466 patients (60 ± 16 years, 49% female, functional TR in 49%). In-hospital mortality rate was 10%. We derived and internally validated a scoring system to predict in-hospital mortality using multivariable logistic regression and bootstrapping with 1000 re-samples. The final risk score ranged from 0 to 12 points and included eight parameters: age ≥70 years, New York Heart Association Class III–IV, right-sided heart failure signs, daily dose of furosemide ≥125 mg, glomerular filtration rate <30 mL/min, elevated bilirubin, left ventricular ejection fraction <60%, and moderate/severe right ventricular dysfunction. Tricuspid regurgitation mechanism was not an independent predictor of outcome. Observed and predicted in-hospital mortality rates increased from 0% to 60% and from 1% to 65%, respectively, as the score increased from 0 up to ≥9 points. Apparent and bias-corrected areas under the receiver operating characteristic curves were 0.81 and 0.75, respectively, much higher than the logistic EuroSCORE (0.67) or EuroSCORE II (0.63). Conclusion : We propose TRI-SCORE as a dedicated risk score model based on eight easy to ascertain parameters to inform patients and physicians regarding the risk of ITVS and guide the clinical decision-making process of patients with severe TR, especially as transcatheter therapies are emerging (www.tri-score.com).