Objectives .– Infective endocarditis (IE) is still associated with a high in-hospital mortality rate of nearly 20%. Heart failure (HF) has been reported as the most common cause of death in IE requiring usually surgical management.

We aimed to analyze clinical characteristics as well as echocardiographic and microbiologic findings to determine prognostic factors and therapeutic implications of HF in patients with IE.

Patients and methods .– From January 1996 to December 2012, all patients with a Duke criteria-based definite diagnosis of IE in a Tunisian high volume tertiary-care centre were included. Clinical and echocardiographic findings, microbiological and therapeutic data were processed.

Results .– Among 284 patients with definite IE included in this analysis, 99 patients had HF (34.9%). Sex ratio was 0.65 (60 men and 39 women). Mean age was 37.3 ± 18 years. Forty-three patients (43.4%) had a history of rheumatic fever with cardiac impairment, 21 patients (21.2%) had valve prostheses. Physical examination had shown fever (84.8%) and heart murmur (65.6%). Vegetation is the common ultrasound finding (84.8%). In 54.7% of cases, the vegetation size exceeded 10 mm. Other devastating effects were revealed such leaflet perforation (13 cases), annular abscess (12 cases), fistula (three cases), mitral chordal rupture (10 cases) and dehiscence of prosthetic valve (11 cases). HF occurred most frequently on native valve (77.7 vs. 22.3% on prosthetic valve; P = 0.004). Blood cultures were negative in 56.5%. Causative microorganisms were Staphylococcus aureus (35 patients), Bartonella spp. (11 patients) and Coxiella burnetti (2 patients). Mean duration of treatment was 40.7 ± 27 days (ranging between four and 180 ). Referral to surgery was more frequent in HF patients (75.7 vs. 27.5%; P < 0.0001). Thirty-four patients died (34.3%) and early recurrence occurred in eight cases. When compared with patients without HF, aortic valve IE, multisite IE, prosthetic valve dehiscence or abscess were more frequently observed in HF patients. Mitral and aortic valve regurgitation, anemia and intracellular microorganism ( Bartonella , Coxiella ) were significantly associated with HF in patients with IE. The mean delay of consultation was longer (26.7 vs. 14.8 days; P = 0.013). HF was independently predictive of in-hospital mortality [HR 3.87 (2.1–7.1); P = 0.0001].

Conclusion .– HF is definitely the most powerful predictor of mortality in IE patients and indicates subsequently urgent surgery. Careful analysis of prognostic factors may improve the management of HF complicating IE.