ABC | Volume 114, Nº1, January 2019

Short Editorial Lamas Infective endocarditis: a deadly disease Arq Bras Cardiol. 2020; 114(1):9-11 who underwent surgery, statistically different compared with 68 years for those who did not undergo surgery. Patients who underwent surgery were more likely to have new moderate or severe mitral or aortic regurgitation, valve perforation or abscess and embolization. In contrast, patients who did not undergo surgical treatment for IE were more likely to have medical comorbidities such as coronary artery disease, previous heart failure, diabetes mellitus and moderate/severe renal disease (findings on comorbidities are similar 3 ) and to have infection caused by S. aureus . In-hospital mortality was 26% vs 14.8% and 6-month mortality 31.4% versus 17.5% among patients who did not undergo surgery compared with those who did, respectively. The reasons for lack of surgery for those who had surgical indications were having a poor prognosis regardless of treatment (33.7%), hemodynamic instability (19.8%), death before surgery (23.3%), stroke (22.7%), and sepsis (21.0%). Sepsis was the single factor associated with nonsurgical management of S. aureus IE compared with other microbiological causes and median STS-IE score for S. aureus patients was higher (32) compared with 24 in non– S aureus patients, with statistical significance. In the study by Marques et al., 1 as expected, septic shock was associated with mortality, with an OR of 20. Sepsis remains a challenge, with very high mortality rates worldwide, especially when associated with shock. 10 Main therapeutic measures are dealt with in the Surviving Sepsis Campaigns, of which the most recent version reinforces speediness in starting intravenous fluids, collecting blood cultures, starting appropriate antibiotics soon after this, measuring lactate, and importantly, starting vasoactive drugs readily (within 1 hour) if intravenous fluids fail to improve blood pressure and normalize lactate levels. 11 Despite the benefits in the survival of surgery, many deaths occur after surgery, and prognostic scores for valvular surgery in IE have been debated in recent years. Mortality rates in the EUROENDO study 3 shows that in hospital post-cardiac surgery mortality was 170/532 (32%) overall, 74/187 (39.6%) if it was prosthetic IE and 79/286 (27.6%) if native valve IE. A recent small study from our team included 154 patients operated for IE from 2006-2016; they were mostly male (66.9%), and mean age was 42.7±15 years. 12 Rheumatic valvulopathy was present in 31.2%; the most frequently isolated microorganisms were viridans group streptococci (29.9%), followed by negative cultures in 26.6% of the patients. The main surgical indication was heart failure (65.6%), and in-hospital mortality was 17.5%. On multivariate analysis, variables found to be statistically significant for death were atrioventricular block, cardiogenic shock, insulin-dependent diabetes mellitus, non-HACEK Gram‑negatives as the etiology of IE and inotropic use. The calculated sensitivity for this was 88.9% and specificity was 91.8%; AUC was 0.97. This was dubbed INC-Rio score, and an app for Android was created (endocarditeinc.org) . In the present study 1 IE with negative blood cultures was associated with mortality; a publication from our group showed that, although there was no difference in mortality for blood culture positive IE and blood culture-negative IE, the latter was associated with more heart failure, which is the main factor associated with death in IE and the main reason to indicate cardiac surgery in most series. 13 In conclusion, the manuscript by Marques et al, despite limited in its inferences due to the retrospective, single‑center nature of the study, is important as it brings to the cardiologists’ attention the issue of the very high mortality associated with IE, especially in a center with no cardiac surgery. The important message is conveyed: left-sided IE is very often a surgical disease, and an endocarditis team is more expedite in recognizing and better treating this condition, especially with respect to indicating surgery, hopefully at its most appropriate moment. Acknowledgments I thank Dr. Carlos Rochitte, editor- in- chief of Arquivos Brasileiros de Cardiologia , for the opportunity of debating infective endocarditis in this prestigious journal, and my colleagues at Instituto Nacional de Cardiologia for their partnership in the “endocarditis team” and in the Mestrado Profissional em Ciências Cardiovasculares. Funding Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro (FAPERJ; grant Jovem Cientista do Nosso Estado, # E26/202.782/2015). 1. Marques A, Cruz I, Caldeira D, Alegria S, Gomes AC, Broa AL et al. Risk Factors for In-Hospital Mortality in Infective Endocarditis. Arq Bras Cardiol. 2020; 114(1):1-8. 2. Murdoch DR, Corey GR, Hoen B, Miró JM, Fowler VG Jr, Bayer AS, et al. Clinical presentation, etiology, and outcome of infective endocarditis in the 21st century: The International Collaboration on Endocarditis-Prospective Cohort Study. Arch Intern Med. 2009;169(5):463-73. 3. Habib G, Erba PA, Iung B, Donal E, Cosyns B, Laroche C et al. Clinical presentation, aetiology and outcome of infective endocarditis. Results of the ESC-EORP EURO-ENDO (European infective endocarditis) registry: a prospective cohort study. Eur Heart J.2019;40(39):3222-32. 4. Thuny F, Grisoli D, Collart F, Habib G, Raoult D. Management of infective endocarditis: challenges and perspectives. Lancet. 2012; 379(9819):965–75. 5. Anantha Narayanan M, Mahfood Haddad T, Kalil AC, Kanmanthareddy A, Suri RM, Mansour G, et al. Early versus late surgical intervention or medical management for infective endocarditis: a systematic review and meta- analysis. Heart. 2016;102(12):950-7. 6. ChuVH,ParkLP,AthanE,DelahayeF,FreibergerT,LamasC,etal.Association between surgical indications,operative risk, and clinical outcome in infective endocarditis: a prospective study from the International Collaboration on Endocarditis. Circulation. 2015 Jan 13;131(2):131-40. 7. HabibG, Lancellotti P, AntunesManuel J, Bongiorni MG, Casalta JP, Del Zotti F, et al. 2015 ESC Guidelines for the management of infective endocarditis (ESC). Eur Heart J. 2015. 36(44):3075–123. 8. Wang A,Chu V, Athan E, Delahaye F, Freiberger T, Lamas C, et al. Association between the timing of surgery for complicated, left-sided infective endocarditis and survival. AmHeart J. 2019 Apr;210:108-16 References 10