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Bilateral valvular involvement in infective endocarditis: A clinically distinct entity? A multicenter retrospective

Ruchi Bhandari¹, Nathan L Maris^2,3, Rowida Mohamed⁴

¹West Virginia University School of Public Health, Morgantown, West Virginia, United States of America.

|November 21, 2025

Insights

Bilateral infective endocarditis (IE) presents unique challenges, combining risks from substance use and medical complexity. This distinct subgroup requires specific attention in future IE research and clinical practice.

Area of Science:

Cardiology
Infectious Diseases
Epidemiology

Background:

Infective endocarditis (IE) is a serious cardiac infection with significant morbidity and mortality.
Valvular involvement in IE varies, impacting risk factors and disease severity.
Understanding these variations is crucial for effective patient management.

Purpose of the Study:

To describe patient characteristics and outcomes based on valvular involvement in infective endocarditis.
To analyze differences between Left-sided (LSIE), Right-sided (RSIE), and Bilateral Infective Endocarditis (BLIE).

Main Methods:

Retrospective multicenter study of 726 adult IE patients (2014-2018).
Data collected via electronic medical chart review.
Analysis categorized IE by valvular involvement (LSIE, RSIE, BLIE) and examined associations with ICU admission using logistic regression.

Main Results:

Drug use, comorbidities, and BLIE/LSIE were linked to increased ICU admission odds.
BLIE patients faced higher clinical burden: more specialist consultations, pain management, higher mortality, and surgical intervention rates.
Patient characteristics, comorbidities, substance use, and outcomes differed significantly across LSIE, RSIE, and BLIE.

Conclusions:

Bilateral infective endocarditis (BLIE) is a distinct IE subgroup.
BLIE combines high-risk substance use (RSIE) with medical complexity (LSIE).
BLIE warrants classification as a separate category in future IE research and clinical studies.

Read full analysis

Abstract

Background:

Infective endocarditis (IE), an infection of the cardiac endothelium, is associated with significant morbidity and mortality. IE cases vary substantially based on their valvular involvement, both in terms of risk factors and severity. This study describes patient characteristics and outcomes associated with valvular involvement in IE.

Methods:

Data for this multicenter, retrospective study were obtained from electronic medical chart review of adult patients hospitalized for their index admission for IE between January 2014- January 2018 in the Appalachian region, USA. Descriptive summary statistics are presented by valvular involvement: (1) Left-sided Infective Endocarditis (LSIE): aortic/mitral valve; (2) Right-sided Infective Endocarditis (RSIE): tricuspid/pulmonary valve; and (3) Bilateral Infective Endocarditis (BLIE): right and left-sided. Multivariable logistic regression analysis examined the association of valvular involvement with intensive care unit (ICU) admission.

Results:

Overall, 726 patients with IE were included in this retrospective study that provides a novel analysis of IE valvular involvement, highlighting how patient characteristics, comorbidities, substance use behaviors, and clinical outcomes differ across LSIE, RSIE, and BLIE presentations. Drug use, the presence of one or two comorbidities, and bilateral or left-sided valve involvement were independently associated with increased odds of ICU admission. Notably, patients with BLIE experienced a greater clinical burden, requiring more frequent specialist consultations, increased use of pain management services, higher mortality, and a higher rate of surgical interventions.

Conclusion:

BLIE represents a clinically distinct IE subgroup characterized by dual vulnerabilities: high-risk substance use behaviors associated with RSIE, and medical complexity typically seen in LSIE. Our findings underscore the importance of including BLIE as a distinct category in future epidemiological and clinical investigations of endocarditis valvular involvement.

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