Imaging REASSESSment of embolic events before antibiotic discontinuation in infective endocarditis: REASSESS-IE study

INTRODUCTION: Embolic events (EEs) in infective endocarditis (IE) are frequent and associated with poor prognosis. Follow-up imaging is not standardized despite the risk of persistent extracardiac foci. We aimed to assess the therapeutic impact of imaging reassessment before antibiotic discontinuation. METHODS AND RESULTS: Prospective multicentre study including patients with definite or possible IE complicated by EEs (2013-2022). Asymptomatic or clinically stable patients who underwent follow-up imaging before antibiotic discontinuation to reassess IE-related EEs were included, whereas those imaged for clinical reasons were excluded. The primary endpoint was therapeutic impact: antibiotic modification and/or intervention. Secondary endpoints included all-cause mortality. Overall, 54% (n = 700/1300) of the entire cohort had IE-related EEs. Among them, 554 patients (mean age 65.7 years, 76% male) under antibiotic therapy were included: 49% with cerebral and 79% with extracerebral EEs, mainly ischaemic stroke (42%) and splenic embolism (40%). Follow-up imaging before antibiotic discontinuation (median, 6 weeks) was performed in 51% (n = 281/554), leading treatment modification in 5.7% (16/281), mainly in patients with Staphylococcus aureus IE complicated by abscess. In-hospital and 5-year mortality were 9.4% and 30.8%, respectively. Haemodynamic instability and comorbidities were associated with long-term mortality, whereas only cardiac surgery was associated with improved survival. CONCLUSION: Imaging reassessment of IE-related EEs before stopping antibiotics may lead to therapeutic modification in asymptomatic or clinically stable patients using a risk-stratified individualized imaging strategy guided by the endocarditis teams, rather than a uniform approach. Prospective studies are needed to define standardized imaging algorithms.