Assessing And Managing Embolic Risk in Left-Sided Infective Endocarditis

Mortality of left-sided infective endocarditis is roughly 20-30%, higher than most types of cancer. Vegetations, the typical morphological lesion of the disease, are friable loose masses, which can easily break and migrate, leading to embolic events (EE) in any vascular territory. When an EE causes a stroke, mortality may increase twofold. Guidelines recognize the prognostic impact of EE and recommend an indication of surgery to prevent EE based on the presence of an EE in the course of the disease and on the vegetation size. However, no strong evidence supports the indication of surgery based on the size. In this review we focus on the risk of embolism, its epidemiology, risk factors, diagnosis and management, underlining the role of surgery. We will propose a change in the current vegetation size-centered approach to prevent EE by highlighting two messages: not only size but also other characteristics of the vegetation are determinant when assessing the risk of having EE; not only the vegetation but other clinical and microbiological aspects are associated with EE. Finally, innovations on this topic such as artificial intelligence and minimally invasive therapeutic approaches are outlined.