Comments on: 'The infective endocarditis team: recommendations from an international working group'

摘要

To the Editor, Chambers et al give some wise recommendations regarding infective endocarditis management. They recognise the grim prognosis of the disease (mortality: 20-64%), the importance of dedicated teams of experts, and the prominent role of early surgery; despite this, they suggest that some patients can be adequately managed in centres without dedicated teams of experts and surgical facilities, and propose nine indications for transfer of patients to a surgical centre. In our opinion, every patient with infective endocarditis should be evaluated and treated in centres with dedicated experts and surgical facilities for several reasons: (1) severe complications may appear at any time and may require urgent diagnosis and treatment by experts; moreover, transferring a patient with septic shock or acute pulmonary oedema contributes to more clinical and haemodynamic instability; (2) an abscess, one of the indications proposed for transferring, and other peri-annular complications, may be missed by non-experts in imaging; (3) failure to respond to antibiotics is defined in the guidelines as the persistence of positive blood cultures 7-10 days after the initiation of antibiotic therapy, but this arbitrary cut-off point may be too late; (4) emboli can be silent or with subtle symptoms, and can be easily missed even by experts; (5) severe regurgitation in the context of a valve with important tissue damage can be difficult to assess. Our experience is in agreement with this concept. We used to recommend that patients could stay at their hospital if no high-risk markers were present; eventually, some of those patients were transferred to our centre with poorer clinical condition. Infective endocarditis is the cardiac disease with the highest rate of death, much higher than acute myocardial infarction and many types of cancers, which needs a combined medico-surgical therapeutic approach, which should be undertaken at medico-surgical centres.