Late Recognition, Unchanged Outcomes: Rethinking Native Valve Endocarditis Care

All articles of this category (opens in new window) Letter to: Endocarditis Through the Ages—What Has Changed During the Past Two Decades Thorac Cardiovasc Surg eFirst DOI: 10.1055/a-2797-9999 10.1055/a-2797-9999 We read with interest the article “Endocarditis Through the Ages—What Has Changed During the Past Two Decades,” which addresses the persistent lack of outcome improvement in native valve endocarditis (NVE) despite advances in multidisciplinary care and perioperative management.[ 1 ] The authors should be commended for their honest appraisal of a challenging and evolving disease. The finding of unchanged outcomes is best understood in the context of contemporary presentation. Current NVE patients are older, more comorbid, caused by virulent and resistant microorganisms and often present late with advanced valvular destruction, heart failure, or embolic complications. Catheter- and drug-induced infective endocarditis affecting the tricuspid valve is increasingly encountered. Importantly, as highlighted in the study, this delay is not driven by prosthetic or transcatheter valve disease but by atypical and insidious presentations of NVE itself, frequently managed initially outside specialized centers. The most common complications of surgery for infective endocarditis remain low cardiac output syndrome, renal failure, perioperative bleeding, conduction disturbances requiring permanent pacing, recurrent infection, and neurological injury.[ 2 ] [ 3 ] [ 4 ] [ 5 ] These complications are magnified when surgery is performed in the setting of advanced sepsis or extensive tissue destruction. Catheter- and drug-induced infective endocarditis affecting the tricuspid valve is increasingly encountered. In severe cases, infection may extend to the cardiac fibrous skeleton, causing extensive destruction that may require complex reconstruction, occasionally resembling Commando or hemi-Commando procedures. This rising incidence contributes to greater surgical complexity and may adversely affect patient outcomes.[ 5 ] [ 6 ] Improving outcomes in NVE will likely require measures beyond team-based decision-making alone. These include heightened early clinical suspicion, faster diagnostic pathways, earlier referral to high-volume centers, and structured triggers for surgical evaluation. In parallel, safer and more targeted antimicrobial strategies are essential. Recent advances in the antibiotic industry—particularly long-acting lipoglycopeptides and optimized bactericidal combinations—offer the potential to reduce toxicity, improve adherence, and better control infection when integrated thoughtfully into endocarditis protocols. In conclusion, the study rightly suggests that modern endocarditis care is being challenged by changing disease biology and patient profiles. Addressing delayed presentation, optimizing timing of surgery, and leveraging advances in antimicrobial therapy may represent the next necessary steps to translate progress into measurable survival benefit. Publication History Received: 05 March 2026 Accepted: 16 March 2026 Article published online: 25 March 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany