Valve-specific structural vulnerability in infective endocarditis: a narrative review of surgical complexity and outcomes.

Authors

Najmi Hakim Abd Rani, Afifah Mohamed, Zaleha Md Isa, Suhaini Kadiman, Taty Anna Kamarudin

Published in

Journal of cardiothoracic surgery. Jul 17, 2026. Epub Jul 17, 2026.

Abstract

Infective endocarditis (IE) carries in-hospital mortality of 15-20% and 1-year mortality approaching 40%, with surgery required in 40-50% of cases. IE is not uniformly distributed across cardiac valves aortic 30-45%, mitral 25-30%, tricuspid 5-10%, pulmonary < 2%, PVE 10-30% and this distribution reflects valve-specific anatomical determinants governing surgical complexity and outcomes. Despite the 2023 ESC Guidelines, a unified structural framework linking anatomical vulnerability to surgical decision-making remains absent.
To propose a valve-specific structural vulnerability framework and examine its implications for surgical complexity, perioperative outcomes, and re-surgery risk across all cardiac valve types.
A narrative review of peer-reviewed literature (2015-2025) was conducted across PubMed, Scopus, and MEDLINE. Systematic reviews, meta-analyses, multicentre registries, and guideline documents were synthesised narratively.
A structural vulnerability gradient (prosthetic valves > aortic > mitral > tricuspid > pulmonary) is proposed as a conceptual model of valve-specific disease behaviour. Aortic IE carries maximal vulnerability through peri-annular extension, 30-40% of cases, requiring radical root reconstruction with elevated operative mortality. Mitral IE exhibits conditional vulnerability; repair yields superior outcomes over replacement. Tricuspid IE is predominantly IVDU-associated with comparatively lower operative mortality. PVE carries the highest operative risk, with prolonged operative times and significant reoperation rates.
IE is best understood as a valve- and substrate-specific disease in which anatomical determinants drive surgical complexity and clinical prognosis. This proposed vulnerability hierarchy may enable preoperative risk stratification, inform valve-specific surgical planning, and provide a mechanistic framework for understanding differential outcomes across valve types. Prospective outcome registries and standardised complexity metrics are needed to validate and refine this conceptual model.

PMID:
42469863
Bibliographic data and abstract were imported from PubMed on 18 Jul 2026.

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