Predictors of Embolism and Death in Left-Sided Infective Endocarditis

Quick Takes

  • Using data from the prospective, multicenter ESC-EORP EURO-ENDO registry, vegetation size >10 mm was associated with a higher rate of the combined endpoint of 30-day embolic event or death.
  • Other predictors of 30-day embolic events or death included embolic event on admission, history of heart failure, creatinine >2 mg/dL, Staphylococcus aureus, congestive heart failure, hemorrhagic stroke, alcohol abuse, cardiogenic shock, and not performing surgery.

Study Questions:

Is there a vegetation size cut-off in left-sided infective endocarditis (IE) that is a predictor of embolic events and 30-day mortality?


The ESC-EORP EURO-ENDO (European Society of Cardiology EURObservational Research Programme European Infective Endocarditis) registry is a prospective, multicenter registry that includes data from patients >18 years of age who presented to an affiliated hospital (156 centers in 40 countries) with definite or possible IE from January 2016–March 2018. The presence and size of vegetations were determined by site echocardiographers. Death was assessed through 1-year follow-up; other complications were assessed until the date of surgery. Cox multivariable logistic regression analysis was performed to assess variables associated with the primary endpoint of 30-day occurrence of embolic events (based on clinical data, computed tomography, or both) or 30-day mortality.


Of 2,171 patients (31.5% women) with left-sided IE, 459 (21.1%) had a new embolic event or died within 30 days. The cut-off size for predicting embolic events or 30-day mortality was >10 mm (hazard ratio [HR], 1.38; 95% confidence interval [CI], 1.13-1.69; p = 0.0015). Other adjusted predictors of 30-day embolic events or death were embolic event on admission (HR, 1.89; 95% CI, 1.54-2.33; p < 0.0001), history of heart failure (HR, 1.53; 95% CI, 1.21-1.93; p = 0.0004), creatinine >2 mg/dL (HR, 1.59; 95% CI, 1.25-2.03; p = 0.0002), Staphylococcus aureus (HR, 1.36; 95% CI, 1.08-1.70; p = 0.008), congestive heart failure (HR, 1.40; 95% CI, 1.12-1.75; p = 0.003), hemorrhagic stroke (HR, 4.57; 95% CI, 3.08-6.79; p < 0.0001), alcohol abuse (HR, 1.45; 95% CI, 1.04-2.03; p = 0.03), cardiogenic shock (HR, 2.07; 95% CI, 1.29-3.34; p = 0.003), and not performing surgery (HR, 1.30; 95% CI, 1.05-1.61; p = 0.016).


The authors conclude that prognosis with left-sided IE is determined by multiple factors including vegetation size.


Several factors are associated with embolic risk among patients with IE, including vegetation location (e.g., mitral valve more than aortic valve), larger vegetation size, causative micro-organism (e.g., Staphylococcus aureus), and prior embolic events. This study, based on a large, multicenter registry, had similar findings specifically among patients with left-sided IE. It is somewhat difficult to interpret the finding that an embolic event at presentation was a risk factor for a combined endpoint of embolic event or death; and silent emboli could have been overlooked because only half of patients underwent positron emission tomography/computed tomography imaging. Although it is unclear from this study whether the performance of surgery is protective against or simply associated with lower rates of embolic events and death, if causation can be established, then these data could help support earlier and/or more aggressive treatment among some patients with left-sided IE.

Clinical Topics: Valvular Heart Disease, Cardiac Surgery and VHD

Keywords: Embolism, Endocarditis, Heart Valve Diseases

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