Infectious endocarditis with multivalvular involvement
Authors: Garcia Leon M C , D'orto M , Martinez M J , Bacigalupe J J , Reyes G R , Mariani J 
Published: January 2025

Abstract

Introduction
Infective endocarditis (IE) with multivalvular involvement (MVIE) is a serious and rare entity, associated with a higher rate of mortality and complications compared to single valve involvement (SVEI). Despite its clinical relevance, it has not been widely studied.
Goals
Describe and compare the clinical, echocardiographic, and microbiological characteristics of patients with MVIE versus SVEI and analyze their in-hospital outcomes.

Materials and methods
Single-center prospective registry of a cohort of patients with definite IE. We included patients over 18 years admitted with a definite diagnosis of IE, according to the modified Duke Criteria, from August 2012 to March 2024. Confirmed or high probability alternative diagnosis, and those with possible IE were excluded.

Results
158 patients with a diagnosis of IE were registered. The median age was 49 and 34% of the population was female. MVIE was present in 21% (34 patients). Of this group, 21% had a history of structural heart disease. Additionally 2.9% had an intracardiac device, 5.9% had a prosthetic valve, and 9.4% had a history of hemodialysis. No significant differences were found between groups. The median number of days until a definitive diagnosis was significantly longer in patients with MVIE (29 vs 15; p=0.025). Blood cultures were negative in 28% of the general population, with no significant differences observed between the groups. The most frequent pathogen in the general population was Staphylococcus (41%), followed by Streptococcus (30%). However, the most frequent pathogen in MVIE was Streptococcus (63% vs 23%; p = 0.005). The most common combination of multivalvular involvement was aortic-mitral (79%). 3 valve involvement was seen in 3 patients (8.8%) and only 1 patient (2.9%) had involvement of all 4 valves.
The median vegetation size in the MVIE was 20 mm. Although no significant differences were found in the size of vegetations compared to SVEI (20 vs 16 mm, p 0.055), the total thrombotic load from multiple valves was greater (23 vs 16 mm; p&lt;0.001). Despite these findings, there were no significant differences regarding peripheral embolisms.
Valve perforation was the most frequent intracardiac complication, observed more often in MVIE (88% vs 51%; p&lt;0.001), followed by pseudoaneurysm, also more frequent in MVIE (44% vs. 18%, p=0.001). No differences were observed in terms of abscesses and intracardiac fistulas.
Heart failure (76% vs 55%, p= 0.023) and use of inotropes (41% vs 23% p 0.030) were more common in MVIE, as was the need for urgent/emergency surgery (42% vs 14%, p=0.001). Overall mortality was significantly higher in MVIE (50% vs 28%, p= 0.017).

Conclusions
The incidence of MVIE was 21%, with aortic and mitral valve involvement being the most common combination. Streptococcus was the most prevalent pathogen. MVIE was associated with a higher rate of intracardiac complications, heart failure, use of inotropes, and greater mortality.
Table 1
Combination valve involvement