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Infective endocarditis is a very complex disease with a serious prognosis. Even if it is not a very common disease most cardiologists are faced with a few number of cases each year, and every case is a difficult one. In the recent Euro Heart Survey for valvar diseases,1 5001 patients with valvar heart disease were included during a three month period from 27 different European countries. Three per cent of them were patients with infective endocarditis and this figure was similar in the different European regions analysed. In recent years advances in echocardiography have resulted in better and earlier diagnosis, and surgical techniques and indications have also changed. In the most recent series including the French registry2 and the Euro Heart Survey data,1 surgery was used in the active phase of the disease in more than 50% of patients.
Even if improvements in both the diagnosis and treatment have occurred mortality figures have not dramatically changed. This lack of improvement in prognosis might be due to the fact that endocarditis is now occurring in old people, in patients unaware of having a cardiac valve disease, in patients with prosthetic valves, and is being caused by aggressive organisms such as staphylococci. Therefore every effort is needed in the field of diagnosis and management strategies. The clinical suspicion of endocarditis should be increased, not only within the scope of patients with previously known heart disease. Clinicians should think of infective endocarditis in every patient presenting with fever and vascular phenomena, even in patients with previously unknown heart disease which represents more than 50% of endocarditis cases. Once the diagnosis is suspected early diagnosis and treatment are mandatory, therefore early access to microbiological and echocardiographic studies are needed. Once the diagnosis is established adequate antibiotics should be used and decisions regarding surgical treatment should be made early and surgery should be performed, when needed, without unnecessary delays.
In his paper Dr Prendergast describes the new diagnostic criteria and explains the difficulties in the diagnosis of the disease, especially in cases with negative blood cultures stressing the need to identify the pathogen using new techniques. Dr Evangelista clarifies the role of echocardiography in the diagnosis of the disease and in the search and diagnosis of complications, and provides a comprehensive scheme for the use of transthoracic and transoesophageal echocardiography. Finally, Dr Delahaye presents a comprehensive practical discussion on surgical indications and timing of surgery. His paper reflects both his large personal experience and the review of the literature and guidelines on this difficult topic.