ABC | Volume 114, Nº3, March 2020

Short Editorial Martins & Lamas Prognostic scores for surgical infective endocarditis Arq Bras Cardiol. 2020; 114(3):525-529 In the STS-IE score, numbers vary from 0-110 points and, according to this model, a patient with 35 points would have an operative risk of at least 10% mortality. 8 Although only patients with IE were studied, this was a voluntary registry of American hospitals only. Important features of IE, such as microbiology, the discrimination between native and prosthetic valves and the presence of intracardiac complications (abscess, fistula) were not analyzed. Surprisingly, 43% of the patients were operated on “electively”, which is a different scenario from other series. Although not specific for endocarditis, Euroscore and Euroscore II take into account active endocarditis as an important variable associated with operative mortality (see Table 1). Importantly, several scores have been created, which are more specific to endocarditis, involving variables that carry a significant weight regarding severity of this condition, 8-13 shown in table 1 of the article by Pivatto Jr F et al. 1 Features specific to IE are prosthetic valve IE, large intracardiac destruction, Staphylococcus spp., pathogen isolated from a blood specimen culture (i.e., positive blood cultures), presence of abscess, perivalvar complications, virulent microorganism; besides these, there is atrioventricular block and non-HACEK Gram negatives (the last 2 for INC-Rio model 4 ) and perivalvular involvement (ex. annular abscess or aortocavitary fistula). 13 When grouped, in addition to prosthesis involvement, essentially type of microorganism and valve destruction (AV block signaling perivalvular abscess) are the distinctive features in these “IE scores” ( see Table 2). We have shown more data on the scores studied by Pivatto Jr F et al. 1 in table 3, and we have added to this the INC-Rio 4 and the DeFeo scores. 13 Mortality and AUC of the scores, relative to their studied population, are shown (Table 3). It is noteworthy that mortality was variable in the different series, and mortality in patients operated with IE was at least double that seen in other types of cardiac surgery (note the lower mortality rates for the populations studied in Euroscore I and II). The present study does not propose a score, and it was added to the table so as to show mortality in their series. In this study 1 , the best O/E mortality ratio was achieved by the PALSUSE score, followed by the logistic EuroSCORE, which had the highest discriminatory power and was significantly superior to EuroSCORE II, STS-IE, PALSUSE, AEPEI and RISK-E. In conclusion, several groups are in search of an adequate score to predict mortality in patients operated for IE. The widely used Euroscore I and II, and the STS-IE have been studied comparatively to the new proposed scores, some of which (for ex., PALSUSE) have included parts of Euroscore to them. In Brazil, only 2 studies (the present one, with 107 patients, and the one by Martins et al. 4 with 154) have addressed the performance of scores in IE, both with small numbers. In the first, the authors concluded that, despite the availability of specific scores, the logistic EuroSCORE was the best to predict mortality in their cohort and no score was proposed; in the second, the mentioned IE scores were not evaluated (most of them published after 2016), but the sensitivity and specificity of Euroscore I was 81.5% and 63%; for Euroscore II , 29.6% and 97.6%, and for STS-IE 7.4% and 98.4%, respectively. AUC values were 0.86 (Euroscore I), 0.90 (Euroscore II) and 0.85 (STS-IE). In the multivariate analysis, the variables found to be statistically significant for death were AV block, cardiogenic shock, insulin- dependent diabetes mellitus, non-HACEK Gram negative microorganisms and inotropic use. These were included in a model, INC-Rio 4 with a calculated sensitivity of 88.9% and specificity of 91.8%; AUC was 0.97. Casalino et al. 14 have studied all-type valvular surgery in 440 patients, in which mortality rate was 16.0% (6.0% in elective surgery and 34.0% in emergency/urgency surgery), and found the AUC was 0.76 for additive and logistic EuroSCORE and 0.81 for EuroSCORE II. They concluded that the EuroSCORE models showed good discriminatory capacity, although calibration was compromised due to mortality underestimation. We believe a multinational study in Brazil would be of paramount importance, with a greater number of patients, to propose and validate a score, since patients with IE in our country dramatically differ from those in North American or European countries, especially due to the high proportion of rheumatic valvopathy, group viridans streptococcal IE, longer delay time to diagnosis, and younger age. Acknowledgments We thank Dr. Carlos Rochitte, Editor-in-chief of Arquivos Brasileiros de Cardiologia , for the opportunity of debating infective endocarditis in this prestigious journal, and our 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). 527