A Plea Not to Forget Infective Endocarditis in COVID-19 Era.

Although recent publications have stressed that the diagnosis and management of acute coronary syndrome should not be neglected during coronavirus disease-2019 (COVID-19) pandemic (1), the issue of infective endocarditis (IE) has not been addressed. IE is associated with a mortality rate of more than 20%, and even 50% when surgery is indicated and not performed (2,3).

We compared the number of cases of IE diagnosed in 2 regional tertiary reference centers from Belgium and France between January 24, 2020 (first COVID-19 case diagnosed in France), and April 30, 2020 (2 weeks after the pandemic peak in France and Belgium), with the number of cases of IE during the same time frame last year. Additionally, we compared the rate of in-hospital complications and mortality between the 2 periods. Data were extracted from a dedicated database compiling all IE cases referred from these regions. This survey was approved by the local ethical committees of both centers and was carried out in accordance with the ethical principles for medical research involving human subjects established by the Declaration of Helsinki, protecting the privacy of all participants.

The percentage of diagnosed IE decreased by 33% during the COVID-19 pandemic (47 patients in 2020 vs. 70 patients in 2019) (Figure 1 ). Furthermore, we observed a worse prognosis in patients diagnosed with IE during the pandemic (i.e., cerebral embolism rate was 18.5% [n = 13] in 2019 vs. 56% [n = 26] in 2020). In-hospital IE mortality reached 61% (n = 29) during the pandemic versus 31% (n = 22) in 2019, which was similar to EURO-ENDO (European Infective Endocarditis Registry) registry results (2). This probably also underlines that patients were referred late, but this hypothesis requires further analysis.

Figure 1

Infective Endocarditis Number During COVID-19 Pandemic Versus the Same Time Frame in 2019

Bar chart displaying the decrease in the number of patients diagnosed with infective endocarditis during COVID-19 (coronavirus disease-2019) pandemic period compared with the same time frame in 2019.

These findings might have several explanations. In the current COVID-19 pandemic, symptoms related to endocarditis might be incorrectly attributed to a diagnosis of SARS-CoV-2 (severe acute respiratory syndrome-coronavirus-2) infection. Moreover, patients might avoid medical care, and hospital resources might be limited due to reorganization during the crisis.

Despite transesophageal echocardiography (TEE) being a very sensitive examination for the diagnosis of IE, current recommendations suggest that its use should be restricted due to high risk of contamination (4). Consequently, we observed a decrease of 49% in the number of TEEs during the pandemic compared with the same time frame in 2019 (498 TEEs in 2019 vs. 244 TEEs in 2020). The substitution of TEE with transthoracic echocardiography might be an explanation for the worse prognosis of patients diagnosed with IE during the pandemic, who potentially have larger vegetations, which might be an indirect gauge of severity.

Alternative techniques, such as computed tomography (CT), have been proposed (3). CT allows rapid scanning, and it is noninvasive, reducing the time and exposure of patients and personnel (4). It can quickly assess valvular and perivalvular involvement, extracardiac complications, and coronary artery anatomy. Moreover, it may be useful for the evaluation of concomitant pulmonary disease (3). In our centers, CT was performed in 32 (68%) patients with IE during the pandemic and in 52 (74%) patients during the same time frame in 2019, respectively.

IE is a deadly disease that requires a rigorous diagnostic and management approach. Current guidelines recommend early surgery in patients with complicated IE (3). When surgery is indicated but not performed, the mortality is around 50% (2).

Despite the fact that COVID-19 pandemic is the new priority for the health care systems worldwide, patients with IE may be at higher risk than before. Disregarding any SARS-CoV-2 coinfection, the patient with IE should be oriented toward an appropriate treatment pathway, based on detailed clinical evaluation and alternative diagnostic methods, decreasing this unacceptable mortality rate.