Embolic risk management in infective endocarditis: predicting the 'embolic roulette'

Life-threatening complications of infective endocarditis (IE,) are heart failure, uncontrolled infection and embolic events (EE), which pose significant morbidity and mortality risks. EE from vegetation rupture are frequent, occurring in more than 50% of patients and can lead to ischaemic stroke and systemic organ infarctions, contributing to poor patient outcomes. Early identification and characterisation of embolic risk factors, including vegetation size, mobility and echogenicity assessed through transthoracic and transoesophageal echocardiography, but also certain pathogens and biomarkers are important for guiding clinical decisions. The latest European Guidelines recommendations emphasise the role of imaging modalities like CT and MRI in detecting silent emboli and guiding therapeutic interventions, including the timely consideration of surgical options to mitigate embolic risks. In this regard, embolic vascular dissemination-including asymptomatic cases detected through multimodality imaging-has been introduced as a new minor criterion for the diagnosis of IE.Depending on the location and severity of the embolism, the embolic risk can either escalate or alternatively, complicate and delay cardiac surgery. The decision to proceed with surgery should not hinge solely on the occurrence of an embolic event, although current guidelines often emphasise this criterion. Therefore, future perspectives should focus on identifying high-risk profiles for EE and investigating whether early surgical intervention benefits these patients, even if they respond favourably to antibiotic therapy. This review explores current literature on echocardiographic and biomarker predictors of EE in IE, aiming to enhance clinical strategies for mitigating embolic complications and improving patient outcomes.