Infective endocarditis (IE) is a disease that is continually changing, with new high risk patients, new diagnostic procedures, the involvement of new microorganisms, and new therapeutic methods.¹ Despite knowledge of these changes, and considerable improvements in diagnostic and therapeutic strategies, IE is still a severe disease.² The high morbidity and mortality rate of IE is the consequence of both the destructive valvar lesions causing valve regurgitation and heart failure, and the valvar vegetations with their high embolic potential. Although the incidence of IE is relatively stable, those patients affected by the disease are older and sicker, and the co-morbidity rate is high.³ As soon as the diagnosis of IE is suspected, the physician is faced with four specific problems:

• First, the diagnosis of IE is still difficult and is frequently delayed, causing progressive and irreparable valvar damage.

• Second, IE is still associated with high in-hospital mortality, ranging from 16–25%, and high incidence of embolic events, ranging from 10–49%, potentially the source of severe complications and sequelae.⁴

• Third, the optimal therapeutic strategy in these patients is still to be defined and may vary in the individual patient.

• Fourth, some patients present with specific features or complications and need a specific management.

These four issues will be addressed here.

HOW TO DIAGNOSE INFECTIVE ENDOCARDITIS?

When to consider IE?

The knowledge of potential at-risk patients may increase the level of suspicion of IE. Although the absolute number of new cases of IE has not changed over the last 10 years, the at-risk population has been completely modified during this period. Rheumatic valve disease is no longer the main underlying disease in IE, and has been replaced by an increasing number of episodes of IE occurring on intracardiac devices, in intravenous drug abusers, and haemodialysis or elderly patients. Nosocomial disease is also much more frequent. Thus, we have to …