Infective endocarditis (IE) is a multifactorial condition with increasing incidence and requires a demanding diagnostic and therapeutic approach supported by multidisciplinary expertise. Over recent years, the number of patients with IE requiring cardiac surgery has risen markedly. The expansion of endovascular interventions has contributed to a population with greater comorbidity and more complex disease profiles. These evolving characteristics have stimulated interest in evaluating the performance and outcomes of different therapeutic strategies in IE.
The purpose of this study was to examine patients diagnosed with IE according to the therapeutic plan adopted: conservative management (Group C) versus surgical treatment (Group Q). This retrospective descriptive study analyzed data collected over a 10-year period (January 2012 to December 2021) at the Department of Cardiac Surgery, LMU University Hospital, Munich, Germany. Demographic characteristics, risk factors, clinical status, echocardiographic and microbiological findings, morbidities, and outcomes were evaluated.
During the study period, 812 patients were admitted with IE. Of these, 30.7% received conservative treatment (Group C), while 69.3% underwent surgery (Group Q). The median age was 72 years in Group C and 67 years in Group Q. A larger proportion of men underwent surgery (Group C: 77.4% vs Group Q: 59.8%). Patients in Group C required intensive care unit (ICU) admission more frequently (34.5% vs 26.5%). EuroSCORE II values were higher in Group C (5.5 vs 5.1), whereas EuroSCORE I values were higher in Group Q (7.6 vs 12.3). Duke criteria were not fulfilled in 36.6% of patients, and these individuals more often received conservative treatment (42.2% vs 34.1%).
Aortic valve IE was treated surgically with greater frequency (65.7% vs 57.8%). Patients with transcatheter aortic valve replacement (TAVR)-associated IE were predominantly managed conservatively (Group C: 8.0% vs Group Q: 3.9%). Patients presenting with severe mitral regurgitation underwent surgery more frequently (Group C: 10% vs Group Q: 22.2%), as did those with evidence of abscess formation (Group C: 7.12% vs Group Q: 28.1%). Conversely, tricuspid valve IE was more often treated conservatively (8.0% vs 4.1%).
Regarding causative pathogens, a higher number of patients with gram-positive IE underwent surgery (Group C: 72.3% vs Group Q: 82.1%), whereas gram-negative infections were more frequently managed conservatively (Group C: 7.2% vs Group Q: 4.1%). Among gram-positive infections, IE due to Staphylococcus aureus was more often managed conservatively (33.3% vs 22.7%), while patients with streptococcal IE more often underwent surgery (20.5% vs 29.1%). Across pathogen types, the highest cumulative mortality was observed in Candida species IE (50.0%). Median ICU stay was longer in Group C (8 vs 4 days). In-hospital mortality was also higher among patients receiving conservative treatment (20.9% vs 12.8%).
COMMENTARY:
Infective endocarditis (IE) remains a major clinical challenge. Its multifactorial nature—shaped by diverse risk factors, multiple predisposing conditions, rising antimicrobial resistance, the expanding use of endovascular procedures, and persistently high mortality—demands a coordinated and multidisciplinary care strategy. These evolving epidemiologic and technical circumstances have progressively increased the proportion of patients requiring surgical intervention, reinforcing the pivotal role of cardiac surgery in contemporary IE management.
The present study aligns with observations reported in the 2023 ESC Clinical Practice Guidelines and contemporary research, emphasizing the necessity of multidisciplinary evaluation and early diagnostic precision to optimize outcomes. The data underscore the benefits of timely surgical intervention in IE, echoing established indications related to hemodynamic deterioration and progression of infection. Notably, the cohort demonstrated lower in-hospital mortality among patients undergoing surgery.
A substantial portion of TAVR-associated IE cases were managed conservatively, consistent with prior reports. The authors highlight the particularly high surgical risk of these patients, acknowledging the technical demands and morbidity associated with TAVR explantation. Nevertheless, surgical intervention remains a viable option when clinically justified.
The findings also reinforce the prognostic relevance of specific pathogens—such as Staphylococcus aureus and Candida species—given their aggressive behavior and association with worse outcomes depending on the therapeutic strategy adopted. The study confirms known limitations of the Duke criteria. Many patients not fulfilling these criteria received conservative management; however, the analysis does not specify the particular criteria that were unmet. These observations strengthen the case for a multimodal diagnostic approach and individualized assessment, aiming to avoid diagnostic delays that may contribute to increased in-hospital mortality.
REFERENCE:
Saha S, Zauner B, Schnackenburg P, Rizas K, Orban M, Massberg S, Hagl C, Joskowiak D.
The Role of Surgery in Contemporary Infective Endocarditis. European Journal of Cardio-Thoracic Surgery. 2025;67(8):ezaf259. doi:10.1093/ejcts/ezaf259.
