Natural History and Evolution of Treatment of Infective Endocarditis

The nature of contemporary infective endocarditis is complex, with a variable natural history conditioned on stage at the time of its presentation, invasiveness, location, proximity to other cardiac structures, and the organism’s virulence. It can change suddenly with septic emboli and with disruption of cardiac structures leading to rapid onset of acute heart failure. It is exacerbated by contemporary heart valve replacement, chronically indwelling intravenous catheters such as for dialysis, intracardiac leads of implantable devices such as pacemakers, and an epidemic of intravenous drug use with its inherent recidivism. Mortality after treatment is related to the same factors associated with higher prevalence of endocarditis—older age and cardiac and noncardiac comorbidity—factors also associated with disproportionate failure of community referral for advanced therapy. The right therapy for infective endocarditis for the right patient at the right time is still debated, and the debate is related in part to the failure to account for influential biases that cloud the picture, and in particular the failure to recognize the importance of conditional natural history. Methods to address both biases and conditional natural history are available and will likely demonstrate that medical management and surgical intervention are not competitive, but complementary, and may be required at different stages of the disease in its conditional natural history for a given patient. Our current approach to infective endocarditis is team-based precision medicine.