Approximately a quarter of patients with infective endocarditis (IE) who have surgical indication only receive antibiotic treatment. Their short-term prognosis is dismal. We aimed to describe the characteristics of this group of patients to evaluate the mortality according to the cause of rejection and type of surgical indication and to analyze their prognostic factors of mortality. From 2005 to 2022, 1105 patients with definite left-sided IE were consecutively attended in three tertiary hospitals. Of them, 912 (82.5%) had formal surgical indication according to the most recent European Guidelines available in each period of the study and 303 (33%) only received medical treatment. These were older, had more comorbidities and higher in-hospital (46% vs. 24%; p < 0.001) and one year mortality (57.1% vs. 27.6%; p < 0.001) than operated patients. The main reason for surgical rejection was high surgical risk (57.1%) and the highest mortality when the cause were severe neurological conditions (76%). When the endocarditis team took the decision not to operate (25.5% of the patients), in-hospital (7%) and one-year mortality (17%) were low. In-hospital mortality associated with each surgical indication was 67% in heart failure, 53% in uncontrolled infection and 45% in prevention of embolisms (p < 0.001). Heart failure (OR: 2.26 CI95%: 1.29–3.96; p = 0.005), Staphylococcus aureus (OR: 3.17; CI95%: 1.72–5.86; p < 0.001) and persistent infection (OR: 5.07 CI95%: 2.85–9.03) are the independent risk factors of in-hospital mortality. One third of the patients with left-sided IE and formal surgical indication are rejected for surgery. In-hospital mortality is very high, especially when heart failure is the indication for surgery and when severe neurological conditions the reason for rejection. Short term prognosis of patients rejected by a specialized endocarditis team is favorable.

Background/Objectives: Heart failure worsens the prognosis of patients with infective endocarditis (IE) and is mainly caused by severe valvular regurgitation. The aim of our investigation is to describe the clinical, epidemiological, microbiological, and echocardiographic characteristics of patients with native left-sided infective endocarditis (NLSIE) with severe valvular regurgitation; to describe the prognosis according to the therapeutic approach; and to determine the prognostic factors of in-hospital mortality. Methods: We prospectively recruited all episodes of possible or definite NLSIE diagnosed at three tertiary hospitals between 2005 and 2022. Patients were divided into two groups: patients with severe valvular regurgitation at the time of admission or during hospitalization and patients without severe valvular regurgitation. We analyzed up to 85 variables concerning epidemiological, clinical, analytical, microbiological, and echocardiographic data. Results: We recovered 874 patients with NLSIE, 564 (65%) of them with severe valvular regurgitation. There were no differences in mortality among patients with and without severe regurgitation (30.2% vs. 26.5%, p = 0.223). However, mortality increased when patients with severe regurgitation developed heart failure (33% vs. 11.4%, p < 0.001). Independent factors related to heart failure were age (OR 1.02 [1.01–1.034], p = 0.001), anemia (OR 1.2 [1.18–3.31], p = 0.01), atrial fibrillation (OR 2.3 [1.08–4.89], p = 0.03), S. viridans-related IE (OR 0.47 [0.3–0.73], p = 0.001), and mitroaortic severe regurgitation (OR 2.4 [1.15–5.02], p = 0.019). Conclusions: Severe valvular regurgitation is very frequent among patients with NLSIE, but it does not worsen the prognosis of patients unless complicated with heart failure.

The CHA₂DS₂-VASc score is widely used to predict thromboembolic events in non-valvular atrial fibrillation (AF) and has also been linked to adverse outcomes in diverse clinical contexts. The latest published European Guidelines on AF recommend the simplified CHA₂DS₂-VA score. Embolic events (EEs) develop in up to 50% of patients with left-sided infective endocarditis (LSIE). Although several variables have been associated with in-hospital mortality and EEs, no standardized risk stratification tool is currently applied in daily practice. Therefore, we sought to assess the prognostic value of the CHA₂DS₂-VA score at admission for predicting both in-hospital mortality and EEs in LSIE. This study included a total of 1420 episodes of definite LSIE diagnosed across three tertiary centers. The CHA₂DS₂-VA score was calculated on admission for all patients. Only cases of clinical EEs occurring in the context of LSIE diagnosis and confirmed by imaging techniques were considered. In-hospital mortality was 28.8% with a stepwise increase according to the CHA₂DS₂-VA score (p < 0.001), regardless of AF history. Multivariable analysis identified this score as an independent predictor of mortality (OR 1.195: 95% CI 1.106–1.291). During hospitalization, 27.5% of patients experienced EEs, but no significant association was observed with the CHA₂DS₂-VA score (p = 0.753). In conclusion, the CHA₂DS₂-VA score emerges as a simple and widely available tool to identify LSIE patients at increased risk of in-hospital mortality, although it does not predict EEs.

Background/Objectives: Prosthetic valve endocarditis (PVE) carries a high morbidity and mortality. Surgery is classically indicated for heart failure, uncontrolled infection, or prevention of embolic events; however, evidence supporting surgery for “non-classical” indications—such as Staphylococcus aureus infection, non-HACEK Gram-negative bacteria, or early PVE—remains limited. This study aimed to update the clinical and prognostic profile of PVE and assess the impact of surgery, particularly in patients with non-classical surgical indications. Methods: We prospectively included all definite left-sided PVE cases diagnosed between 2000 and 2024 at three tertiary centers. Clinical, microbiological, echocardiographic, and prognostic data were analyzed and compared. Predictors of in-hospital mortality were identified using multivariable logistic regression, and Kaplan–Meier curves were used to compare 1-year survival according to surgical indications. Results: Among 589 patients with left-sided PVE, 61% underwent surgery, and in-hospital mortality was 31%. Independent mortality predictors were chronic obstructive pulmonary disease, pulmonary hypertension, periannular complications, S. aureus infection, and poor clinical condition at admission. Non-classical surgical indications were present in 38% of patients, although only 28 (5%) of them had no other surgical indication. These patients exhibited lower mortality (14%) and no survival benefit from surgery (10% vs. 17%; p 0.999). Conclusions: PVE remains associated with high mortality. Surgery improves survival in patients with classical surgical indications but not in patients with non-classical indications, supporting individualized surgical decisions by a multidisciplinary endocarditis team.