Risk of embolism and death in infective endocarditis: Prognostic value of echocardiography - A prospective multicenter study

Background - The incidence of embolic events (EE) and death is still high in patients with infective endocarditis (IE), and data about predictors of these 2 major complications are conflicting. Moreover, the exact role of echocardiography in risk stratification is not well defined. Methods and Results - In a multicenter prospective European study, including 384 consecutive patients (aged 57 +/- 17 years) with definite IE according to Duke University criteria, we tested clinical, microbiological, and echocardiographic data as potential predictors of EE and 1-year mortality. Transesophageal echocardiography was performed in all patients. Embolism occurred before or after IE diagnosis (total-EE) in 131 patients ( 34.1%) and after initiation of antibiotic therapy (new- EE) in 28 patients (7.3%). Staphylococcus aureus and Streptococcus bovis were independently associated with total-EE, whereas vegetation length similar to 10 mm and severe vegetation mobility were predictors of new- EE, even after adjustment for S aureus and S bovis. One-year mortality was 20.6%. In multivariable analysis, independently of the other predictors of death ( age, female sex, creatinine serum > 2 mg/L, moderate or severe congestive heart failure, and S aureus) and comorbidity, vegetation length > 15 mm was a predictor of 1-year mortality ( adjusted relative risk = 1.8; 95% CI, 1.10 to 2.82; P = 0.02). Conclusions - In IE, vegetation length is a strong predictor of new- EE and mortality. In combination with clinical and microbiological findings, echocardiography may identify high-risk patients who will need a more aggressive therapeutic strategy.