ABC | Volume 114, Nº1, January 2019

Original Article Marques et al. In-hospital mortality in infective endocarditis Arq Bras Cardiol. 2020; 114(1):1-8 Prosthetic valve endocarditis occurred in 25%, in the range described in literature (10–30%). 3,7,8,13,14 Healthcare-associated IE represents up to 30% of IE cases 8,13 and in this study occurred in 22.4%. Agents from Staphylococcal and Streptococcal species were the most isolated microorganisms (around 30%), like expected. 3,7,8,15 Negative-blood culture IE occurred in 21.6%, a proportion that overlaps the data found in the literature (2.1-35%). 8,14,18 Transesophageal echocardiography (TEE) was performed in 88%. The remaining patients did not have clinical conditions to undergo a TEE or died before TEE performance. The two main echocardiographic findings were vegetations (79.1%) and valve regurgitation (51.5%). Due to lack of 18 F-FDG PET/CT scan and radiolabeled WBC SPECT/CT availability in our center, only 1 patient performed PET 18 F-FDG PET/CT scan (in other center) and none performed radiolabeled leukocytes SPECT/CT. Expectedly, heart failure was the main adverse event observed during hospitalization (48.5%). 3,8 Complications, length of hospital stay, and mortality remain high in IE 1 and our data highlight these facts. This study identified the high-risk features on endocarditis patients in our cohort. The early identification of these patients might be helpful in outcome improvement by managing more closely and delivering early cardiac surgery when indicated. These results are important not only for clinicians, once they highlighted the risk factors of death, but also to cardiac surgeons, given that they showed the good impact in prognosis of cardiac surgery. It is important to continue with further investigations to identify other factors that could minimize the mortality levels of IE on top of the best-known management. Limitations This study had a retrospective design and the information was limited to medical records. The absence of systematically collected data (such as echocardiographicmeasures) derived from the study design, prevented the possibility of further estimating the impact of IE in other important healthcare variables. This study was also performed in a single center without on‑site cardiac surgery and the regional variation in the diagnosis, treatment, local microbiology of IE could have influenced results and preclude the robustness of the conclusions. The sample size is unlikely to be adequately powered to assess the in-hospital mortality and risk factors. The referral bias, particularly in patients not accepted for cardiac surgery needs to be acknowledged as a limitation. Conclusions According to our data, the risk factors for in-hospital mortality were the development of heart failure or septic shock, evidence of valve obstruction in echocardiography, Staphylococcus aureus etiology or blood-culture negative endocarditis. Invasive treatment by surgery significantly decreased the mortality risk. These results are important for all participants and emphasize the importance of having a multidisciplinary Endocarditis Team (with specialists in Internal Medicine, Cardiology, Microbiology, Infectious diseases, Cardiac Surgery) in order to address all the features associated to increased mortality. Author contributions Conception and design of the research: Cruz I, Broa AL; Acquisition of data: Marques A, Cruz I, Alegria S, Gomes AC, Broa AL; Analysis and interpretation of the data: Marques A, Cruz I, Gomes AC, Broa AL; Statistical analysis: Marques A, Caldeira D, Broa AL; Writing of the manuscript: Marques A, Caldeira D, Alegria S; Critical revision of the manuscript for intellectual content: Caldeira D, João I, Pereira H. Author contributions Conception and design of the research: Cruz I, Broa AL; Acquisition of data: Marques A, Cruz I, Alegria S, Gomes AC, Broa AL; Analysis and interpretation of the data: Marques A, Cruz I, Gomes AC, Broa AL; Statistical analysis:Marques A, Caldeira D, Broa AL; Writing of the manuscript: Marques A, Caldeira D, Alegria S; Critical revision of the manuscript for intellectual content: Caldeira D, João I, Pereira H. Potential Conflict of Interest No potential conflict of interest relevant to this article was reported. Sources of Funding There were no external funding sources for this study. Study Association This study is not associatedwith any thesis or dissertationwork. Ethics approval and consent to participate This study was approved by the Ethics Committee of the Hospital Garcia Orta under the protocol number 31/2017. All the procedures in this study were in accordance with the 1975 Helsinki Declaration, updated in 2013. 7