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cardio.cardiogenic-shock.acute-mr-endocarditis.v1PRODUCTION
cardio.cardiogenic-shock.acute-mr-endocarditis.v1

Cardiogenic shock — acute severe MR from infective endocarditis

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Detailed

Confirm IE-driven acute severe MR as the cardiogenic shock etiology — fever + new holosystolic murmur + flash pulm edema + hemodynamic deterioration in patient with IE risk factors (IVDU, prosthetic valve, CIED, indwelling line, prior IE); identify mechanism (leaflet perforation vs chordal destruction vs ring extension)

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IE-driven acute MR confirmed as working diagnosis with mechanism stated

Patient inputs (24)

GOLD STANDARD for IE — vegetation visualization (size + mobility), leaflet defect / perforation, regurgitation severity (PISA, vena contracta, EROA), ring abscess (perivalvular extension), prosthetic dehiscence

Septic emboli to brain (stroke, mycotic aneurysm) — common in left-sided IE; impacts surgical timing (delay if hemorrhagic stroke)

Older patients higher operative risk; younger IVDU patients distinct demographic; informs surgical-risk stratification + TEER candidacy

Sinus tachycardia + fever (sepsis); new AV block raises perivalvular abscess concern (esp with aortic IE extending to AV groove)

Fever supports IE; afebrile presentation possible in subacute IE / immunocompromised / prior antibiotics

AKI from sepsis + low forward flow + nephrotoxic antibiotics (vancomycin, gentamicin); contrast nephropathy risk for cath/CTA

Major IE risk factor (right-sided IE more common but left-sided also occurs); high re-IE rate without addiction treatment

Prosthetic valve IE has higher mortality + requires surgery + extended antibiotic course (6 wk + rifampin/gentamicin per AHA 2015)

Drives empiric antibiotic selection — vanc + cefepime alternative if severe penicillin/cephalosporin allergy precludes ceftriaxone

Flash pulmonary edema severity tracker; intubation often needed

FOUNDATIONAL — three sets from separate sites BEFORE antibiotics; modified Duke criteria major criterion; drives organism-specific antibiotic regimen

Leukocytosis with left shift in acute IE; anemia / hemolysis (mechanical hemolytic anemia from regurgitant jet); thrombocytopenia in sepsis

CRP + ESR support IE diagnosis (modified Duke minor criterion); trend therapeutic response

Elevated if myocardial extension / septic emboli / type 2 MI; trends ongoing ischemia

Acute volume overload marker; trend tracks decongestion + recovery

Hematuria + proteinuria (immune-mediated glomerulonephritis from IE); modified Duke minor criterion

Bedside TTE for initial screen — flail leaflet, vegetation, biventricular function; PRELIMINARY only — TEE is gold standard for IE

Sinus tachy / AF; new AV block raises perivalvular abscess concern (esp aortic root abscess extending to AV groove)

Flash pulmonary edema with normal-sized cardiac silhouette; septic emboli appear as wedge-shaped infarcts (right-sided IE) or peripheral nodules

SCAI 2022 staging baseline; SBP <90 + flash pulm edema + fever = IE-driven acute MR with CS / sepsis overlap

SCAI 2022 staging + sepsis severity; CardShock prognostication (Harjola EHJ 2015 PMID 26333869); SSC 2021 sepsis bundle

Perivalvular abscess / fistula characterization (better than TEE for some abscess locations); coronary angiography substitute pre-op (avoids embolization risk of cath in active IE)

CIED (pacemaker / ICD) lead infection / vegetation requires device extraction per HRS 2017 expert consensus

Bacteremia risk; helps identify portal of entry (helps source control)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (5)

5 need judgement
  • informationallife_threateningemergent_surgery_decision_in_active_sepsis
    IE-driven acute severe MR + HF symptoms + uncontrolled infection + active sepsis — emergent surgery indication despite operative risk; balance source control vs sepsis stabilization
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningseptic_embolus_with_stroke_complicates_surgical_timing
    Septic embolus to brain causing stroke (especially hemorrhagic) — complicates timing of cardiac surgery (typically delay 2-4 weeks for ischemic stroke, longer if hemorrhagic) but balance vs ongoing IE control
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningparavalvular_abscess_on_tee_requires_emergent_surgery
    Paravalvular abscess / fistula / heart block on TEE — Class I emergent surgery indication; abscess frequently associated with new AV block (esp aortic IE extending to AV groove)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererecurrent_ie_on_iv_drug_use_long_term_management
    IVDU patient with second or recurrent IE — significantly higher mortality + complex surgical decision-making + addiction medicine integral
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereflash_pulmonary_edema_refractory_to_diuretic_in_ie_acute_mr
    Refractory flash pulmonary edema in IE-driven acute severe MR despite IV nitrate + diuretic + IABP — intubation needed; expedite surgery
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

IE-driven acute severe MR + CS — empiric IV antibiotics IMMEDIATELY + emergent surgery (Class I) + IABP bridge (preferred MCS) + cautious inotrope + diuretic + afterload reduction; AVOID isolated vasoconstrictor; SOURCE CONTROL critical
axis: ie_driven_acute_mr_cs_phenotype
Selected axis "IE-driven acute severe MR + CS — empiric IV antibiotics IMMEDIATELY + emergent surgery (Class I) + IABP bridge (preferred MCS) + cautious inotrope + diuretic + afterload reduction; AVOID isolated vasoconstrictor; SOURCE CONTROL critical" by default fallback (first axis)
  • vancomycin
    first line
    glycopeptide_antibiotic
    25–30 mg/kg IV load then 15–20 mg/kg q12h adjusted to trough 15–20 • IV • q12h
    triggers: ie_with_acute_mr_empiric, mrsa_coverage, awaiting_blood_culture_results
    AHA 2015 endocarditis guideline (Baddour PMID 26373316) + ESC 2023 update (Delgado PMID 37622660) — empiric coverage for native valve IE includes MRSA coverage given high prevalence; trough-targeted dosing per IDSA 2020 vancomycin guideline
    rxcui 11124
  • ceftriaxone
    first line
    cephalosporin_3rd_gen
    2 g IV q24h • IV • q24h
    triggers: ie_with_acute_mr_empiric, streptococcus_or_hacek_coverage, awaiting_blood_culture_results
    AHA 2015 endocarditis guideline — empiric coverage for Streptococcus viridans + HACEK organisms
    rxcui 2193
  • cefepime
    second line
    cephalosporin_4th_gen
    2 g IV q8h • IV • q8h
    triggers: hcap_risk_factors, pseudomonas_coverage_needed, iv_drug_use_with_severe_sepsis
    AHA 2015 endocarditis guideline — alternative empiric with broader gram-negative coverage when HCAP risk or IVDU with severe sepsis
    rxcui 20481
  • gentamicin
    add on
    aminoglycoside
    1 mg/kg IV q8h adjusted to peak/trough • IV • q8h
    triggers: prosthetic_valve_ie, enterococcus_ie, staphylococcus_prosthetic_valve_ie
    AHA 2015 endocarditis guideline — adjunct for prosthetic valve IE (× 2 weeks per protocol) and enterococcal IE (synergy with cell-wall agent); monitor renal function + ototoxicity
    rxcui 1596450
  • rifampin
    add on
    rifamycin
    300 mg PO/IV q8h • PO/IV • q8h
    triggers: prosthetic_valve_ie_with_staphylococcus
    AHA 2015 endocarditis guideline — biofilm penetration in prosthetic valve staphylococcal IE; × full 6-week course
    rxcui 9384
  • daptomycin
    second line
    lipopeptide_antibiotic
    8–12 mg/kg IV q24h • IV • q24h
    triggers: vancomycin_intolerance_or_resistance, mrsa_with_high_vanc_mic
    AHA 2015 endocarditis guideline + IDSA — alternative to vancomycin for MRSA / VRE IE; high doses (8-12 mg/kg) needed for IE per Fowler NEJM 2006
    rxcui 22299
  • norepinephrine
    first line
    vasopressor_alpha
    0.05–0.5 µg/kg/min titrate MAP ≥65 • IV • continuous
    triggers: ie_acute_mr_cs_with_sbp_lt_90, sepsis_distributive_shock_overlay
    SOAP-II PMID 20200382 — NE first-line in CS / septic shock; CAUTION — pair with afterload reduction in acute MR to prevent worsening regurgitant fraction
    rxcui 7512
  • dobutamine
    second line
    inotrope_beta1
    2.5 µg/kg/min CAUTIOUS titration • IV • continuous
    triggers: low_cardiac_output_despite_NE_and_iabp, no_active_arrhythmia
    DOREMI PMID 33704937 — non-inferior to milrinone; CAUTION in acute MR (may worsen MR severity by increasing LV contractility)
    rxcui 3616
  • sodium nitroprusside
    first line
    arteriovenodilator
    0.25–0.5 µg/kg/min start; titrate to MAP 65–75 • IV • continuous
    triggers: acute_severe_mr_with_pulm_edema_and_adequate_map, need_afterload_reduction
    Cornerstone afterload reduction in acute severe MR — reduces regurgitant fraction + improves forward flow + reduces pulmonary edema; cyanide accumulation risk if eGFR <30
    rxcui 9895
  • nitroglycerin
    first line
    venodilator
    5–20 µg/min titrate up to 200 µg/min • IV • continuous
    triggers: flash_pulmonary_edema_in_ie_acute_mr, preload_reduction_needed
    Preload reduction → reduces PCWP + V-wave + pulm edema; first-line decongestant in acute MR with preserved MAP
    rxcui 4917
  • furosemide
    first line
    loop_diuretic
    40–80 mg IV bolus then infusion 5–10 mg/h • IV • bolus + continuous
    triggers: flash_pulmonary_edema, volume_overload_with_adequate_perfusion
    Decongest after perfusion stable (ESC 2021 HF Guidelines); continuous infusion preferred for refractory pulm edema
    rxcui 4603
  • vasopressin
    add on
    V1_agonist
    0.03 U/min fixed • IV • continuous
    triggers: NE_above_0.5_with_persistent_hypotension_in_septic_shock_overlay
    V1-mediated; pulmonary-vascular sparing; SSC 2021 sepsis bundle adjunct to NE; per VANISH trial
    rxcui 11149
  • warfarin
    first line
    vitamin_k_antagonist
    Post-op: 5 mg daily; mechanical mitral INR target 2.5–3.5; bioprosthetic INR 2–3 × 3 mo then ASA • PO • daily
    triggers: mechanical_mitral_valve_post_op, bioprosthetic_mitral_valve_first_3_mo
    ACC/AHA 2020 valvular Class I — mechanical mitral valve requires lifelong warfarin INR 2.5–3.5; bioprosthetic INR 2–3 × 3 mo then ASA chronic
    rxcui 11289

outpatient playbook — drug actions (5)

  1. 1. continue warfarin lifelong (mechanical) or × 3 mo (bioprosthetic)
    rxcui 11289
    INR 2.5–3.5 mechanical / 2–3 × 3 mo bioprosthetic • PO • daily
    trigger: Post-op valve replacement
    ACC/AHA 2020 valvular Class I — lifelong for mechanical, 3 mo + ASA chronic for bioprosthetic
  2. 2. continue or up-titrate GDMT 4-pillar if persistent EF<40
    lisinopril or sac/val + carvedilol + MRA + SGLT2i • PO • daily/BID
    trigger: Persistent EF<40
    AHA/ACC/HFSA 2022 HF Guideline (PMID 35363499)
  3. 3. continue aspirin 81 mg if bioprosthetic
    rxcui 243670
    81 mg PO daily • PO • daily
    trigger: Bioprosthetic MV
    ACC/AHA 2020 valvular Class IIa lifelong
  4. 4. amoxicillin 2 g 30-60 min before dental procedures
    rxcui 723
    2 g PO • PO • before procedure
    trigger: Prosthetic valve / prior IE / congenital heart disease + dental procedure with bleeding risk
    AHA 2007 endocarditis prophylaxis
  5. 5. continue addiction medicine pharmacotherapy if IVDU
    per addiction medicine • PO/SL • daily
    trigger: IVDU etiology
    ASAM standards; lifelong for sustained recovery

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Fever + new harsh holosystolic murmur at apex + flash pulmonary edema + hemodynamic deterioration → IE-driven acute severe MR with CS until proven otherwise; STAT TEE: mitral valve vegetation ≥10 mm + leaflet perforation / chordal destruction + acute severe MR (vena contracta ≥0.7 cm, EROA ≥0.4 cm²) + biventricular dysfunction + shock physiology; Positive blood cultures (S. aureus, Streptococcus viridans, enterococcus) + sudden cardiac decompensation → acute MR from leaflet perforation / chordal destruction.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Cardiogenic shock — acute severe MR from infective endocarditis** (cardio.cardiogenic-shock.acute-mr-endocarditis.v1).
Scope: Confirm IE-driven acute severe MR as the cardiogenic shock etiology — fever + new holosystolic murmur + flash pulm edema + hemodynamic deterioration in patient with IE risk factors (IVDU, prosthetic valve, CIED, indwelling line, prior IE); identify mechanism (leaflet perforation vs chordal destruction vs ring extension)

No severity triggers fired against current inputs.

Plan

Regimen axis: **IE-driven acute severe MR + CS — empiric IV antibiotics IMMEDIATELY + emergent surgery (Class I) + IABP bridge (preferred MCS) + cautious inotrope + diuretic + afterload reduction; AVOID isolated vasoconstrictor; SOURCE CONTROL critical**.
1. vancomycin 25–30 mg/kg IV load then 15–20 mg/kg q12h adjusted to trough 15–20 IV q12h (glycopeptide_antibiotic, first line) — AHA 2015 endocarditis guideline (Baddour PMID 26373316) + ESC 2023 update (Delgado PMID 37622660) — empiric coverage for native valve IE includes MRSA coverage given high prevalence; trough-targeted dosing per IDSA 2020 vancomycin guideline
2. ceftriaxone 2 g IV q24h IV q24h (cephalosporin_3rd_gen, first line) — AHA 2015 endocarditis guideline — empiric coverage for Streptococcus viridans + HACEK organisms
3. cefepime 2 g IV q8h IV q8h (cephalosporin_4th_gen, second line) — AHA 2015 endocarditis guideline — alternative empiric with broader gram-negative coverage when HCAP risk or IVDU with severe sepsis
4. gentamicin 1 mg/kg IV q8h adjusted to peak/trough IV q8h (aminoglycoside, add on) — AHA 2015 endocarditis guideline — adjunct for prosthetic valve IE (× 2 weeks per protocol) and enterococcal IE (synergy with cell-wall agent); monitor renal function + ototoxicity
5. rifampin 300 mg PO/IV q8h PO/IV q8h (rifamycin, add on) — AHA 2015 endocarditis guideline — biofilm penetration in prosthetic valve staphylococcal IE; × full 6-week course
6. daptomycin 8–12 mg/kg IV q24h IV q24h (lipopeptide_antibiotic, second line) — AHA 2015 endocarditis guideline + IDSA — alternative to vancomycin for MRSA / VRE IE; high doses (8-12 mg/kg) needed for IE per Fowler NEJM 2006
7. norepinephrine 0.05–0.5 µg/kg/min titrate MAP ≥65 IV continuous (vasopressor_alpha, first line) — SOAP-II PMID 20200382 — NE first-line in CS / septic shock; CAUTION — pair with afterload reduction in acute MR to prevent worsening regurgitant fraction
8. dobutamine 2.5 µg/kg/min CAUTIOUS titration IV continuous (inotrope_beta1, second line) — DOREMI PMID 33704937 — non-inferior to milrinone; CAUTION in acute MR (may worsen MR severity by increasing LV contractility)
9. sodium nitroprusside 0.25–0.5 µg/kg/min start; titrate to MAP 65–75 IV continuous (arteriovenodilator, first line) — Cornerstone afterload reduction in acute severe MR — reduces regurgitant fraction + improves forward flow + reduces pulmonary edema; cyanide accumulation risk if eGFR <30
10. nitroglycerin 5–20 µg/min titrate up to 200 µg/min IV continuous (venodilator, first line) — Preload reduction → reduces PCWP + V-wave + pulm edema; first-line decongestant in acute MR with preserved MAP
11. furosemide 40–80 mg IV bolus then infusion 5–10 mg/h IV bolus + continuous (loop_diuretic, first line) — Decongest after perfusion stable (ESC 2021 HF Guidelines); continuous infusion preferred for refractory pulm edema
12. vasopressin 0.03 U/min fixed IV continuous (V1_agonist, add on) — V1-mediated; pulmonary-vascular sparing; SSC 2021 sepsis bundle adjunct to NE; per VANISH trial
13. warfarin Post-op: 5 mg daily; mechanical mitral INR target 2.5–3.5; bioprosthetic INR 2–3 × 3 mo then ASA PO daily (vitamin_k_antagonist, first line) — ACC/AHA 2020 valvular Class I — mechanical mitral valve requires lifelong warfarin INR 2.5–3.5; bioprosthetic INR 2–3 × 3 mo then ASA chronic

Setting playbook (outpatient) — 1 mo + 3 mo + 6 mo + annual valve / IE clinic surveillance — confirm valve function + LV recovery + sustained sterilization + INR control + GDMT optimization + endocarditis prophylaxis + lifelong follow-up + addiction medicine if IVDU
14. continue warfarin lifelong (mechanical) or × 3 mo (bioprosthetic) INR 2.5–3.5 mechanical / 2–3 × 3 mo bioprosthetic PO daily — Post-op valve replacement (ACC/AHA 2020 valvular Class I — lifelong for mechanical, 3 mo + ASA chronic for bioprosthetic)
15. continue or up-titrate GDMT 4-pillar if persistent EF<40 lisinopril or sac/val + carvedilol + MRA + SGLT2i PO daily/BID — Persistent EF<40 (AHA/ACC/HFSA 2022 HF Guideline (PMID 35363499))
16. continue aspirin 81 mg if bioprosthetic 81 mg PO daily PO daily — Bioprosthetic MV (ACC/AHA 2020 valvular Class IIa lifelong)
17. amoxicillin 2 g 30-60 min before dental procedures 2 g PO PO before procedure — Prosthetic valve / prior IE / congenital heart disease + dental procedure with bleeding risk (AHA 2007 endocarditis prophylaxis)
18. continue addiction medicine pharmacotherapy if IVDU per addiction medicine PO/SL daily — IVDU etiology (ASAM standards; lifelong for sustained recovery)

Non-pharmacologic actions:
- Cardiac rehab maintenance phase
- Annual influenza + pneumococcal + COVID-19 vaccination
- Dental cleanings q6 mo with endocarditis prophylaxis
- Valve / IE clinic lifelong follow-up
- Pregnancy counseling (mechanical valve + warfarin teratogenicity)
- Addiction medicine lifelong follow-up if IVDU
- Skin / wound care education to prevent re-bacteremia

AVOID / contraindication checks:
- Do_not_delay_blood_cultures_before_antibiotics (modified Duke criteria foundation)
- Do_not_delay_surgery_for_prolonged_antibiotic_course_in_active_ie_with_HF (AHA 2015 + ESC 2023 + Wang JAMA 2014 PMID 24247733)
- Isolated_vasoconstrictor_AVOID_in_acute_mr_without_afterload_reduction (worsens regurgitant fraction)
- Beta_blocker_AVOID_in_cardiogenic_shock (ACC/AHA 2022)
- Nitrates_caution_with_severe_hypotension (titrate to MAP ≥65 first)
- Nitroprusside_cyanide_risk_if_egfr_lt_30 (use sodium thiosulfate cofactor; alternative agents preferred)
- High_dose_dobutamine_minimize_in_acute_mr (may worsen MR severity)
- LV_only_Impella_complex_in_acute_mr (can worsen MR by altering coaptation; IABP generally preferred bridge per acute MR physiology)
- Routine_VA_ECMO_AVOID_in_acute_mr (no specific benefit shown; surgery is the definitive treatment)
- Doac_AVOID_in_mechanical_valve (warfarin only per ACC/AHA 2020)
- Therapeutic_anticoagulation_caution_in_active_ie_with_septic_emboli (hemorrhagic conversion risk; balance vs valve type)
- Vancomycin_trough_15 20_target_for_ie (IDSA 2020)
- Gentamicin_avoid_aki_or_ototoxicity (monitor renal + audiometry if prolonged)
- Retain_infected_cied_AVOID — extract per HRS 2017 expert consensus

Monitoring

Regimen monitoring:
- arterial line continuous BP (ACC/AHA 2022 Class I)
- central venous access (ACC/AHA 2022)
- PA catheter for PCWP and v wave trend (helpful in acute MR for response assessment)
- lactate q1-2h (CardShock + SSC 2021)
- UOP hourly (SCAI 2019 end-organ perfusion marker)
- serial blood cultures q24-48h until sterile (sterilization tracking)
- serial echo q12-24h post op for valve function (ACC/AHA 2020 valvular)
- continuous telemetry for arrhythmia and new av block (ring abscess marker)
- daily BNP and troponin and inflammatory markers (trend tracks recovery + sterilization)
- INR daily during warfarin initiation post op (target per valve type)
- weekly vancomycin trough (15-20 target)
- weekly LFT and CBC during antibiotics (toxicity surveillance)
- audiometry if prolonged gentamicin (ototoxicity)

Setting (outpatient) monitoring:
- Echo at 1 mo + 3 mo + 6 mo + annually
- INR per protocol
- BMP + lipid annually
- CRP/ESR for re-IE surveillance annually

Follow-up plan: Repeat TTE / TEE at 1 wk + 1 mo + 3 mo + 6 mo + annually post-surgery; complete prolonged IV antibiotic course (4-6 weeks for native valve, 6 weeks + rifampin/gentamicin for prosthetic valve per AHA 2015); cardiac rehab; GDMT if persistent HFrEF; endocarditis prophylaxis per AHA 2007 (lifelong for prosthetic valves, prior IE, congenital heart disease); long-term anticoagulation per valve type; addiction medicine follow-up if IVDU; dental clearance + planned dental work; lifelong follow-up at valve / IE clinic
- Close-out criterion: Recovery echo, IE/valve clinic follow-up, GDMT, long-term anticoag plan, addiction medicine if IVDU, prophylaxis education booked

Monitoring phase: A-line, central line, PA catheter for PCWP + V-wave trend, lactate clearance, urine output; continuous telemetry; serial blood cultures (sterilization tracking); serial echo q12-24h post-surgery for valve function + LV recovery; daily BNP + inflammatory markers + troponin; weekly LFT + CBC for antibiotic toxicity

Disposition

Current setting: outpatient — 1 mo + 3 mo + 6 mo + annual valve / IE clinic surveillance — confirm valve function + LV recovery + sustained sterilization + INR control + GDMT optimization + endocarditis prophylaxis + lifelong follow-up + addiction medicine if IVDU

Disposition criteria:
- Stable valve function + LVEF preserved + sustained sterilization + addiction stable if IVDU → annual valve / IE clinic follow-up
- Persistent HFrEF → long-term cross-link to cardio.hfref.core.v1 / cardio.hf.core.v1

Escalation triggers (move to higher acuity):
- Symptomatic prosthetic valve dysfunction → emergent valve clinic
- New murmur → echo + valve clinic
- Fever with prosthetic valve → ED + IE re-workup (very low threshold)
- Bleeding on warfarin → ED + reversal
- Addiction relapse → addiction medicine urgent + IE surveillance

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] IE-driven acute severe MR + HF symptoms + uncontrolled infection + active sepsis — emergent surgery indication despite operative risk; balance source control vs sepsis stabilization
- [LIFE_THREATENING] Septic embolus to brain causing stroke (especially hemorrhagic) — complicates timing of cardiac surgery (typically delay 2-4 weeks for ischemic stroke, longer if hemorrhagic) but balance vs ongoing IE control
- [LIFE_THREATENING] Paravalvular abscess / fistula / heart block on TEE — Class I emergent surgery indication; abscess frequently associated with new AV block (esp aortic IE extending to AV groove)

Citations

- Baddour AHA Infective Endocarditis 2015 (PMID 26373316); Delgado ESC Endocarditis 2023 update (PMID 37622660); Otto ACC/AHA 2020 valvular heart disease guideline (PMID 33342587); Wang JAMA 2014 — early surgery in IE survival benefit (PMID 24247733); Estévez-Loureiro JACC 2024 IREMMI registry (PMID 36440867); SCAI 2022 CS staging (Naidu PMID 35718438) [PMID:26373316](https://pubmed.ncbi.nlm.nih.gov/26373316/)
- Cited evidence (PMID 37622660) [PMID:37622660](https://pubmed.ncbi.nlm.nih.gov/37622660/)
- Cited evidence (PMID 33342587) [PMID:33342587](https://pubmed.ncbi.nlm.nih.gov/33342587/)
- Cited evidence (PMID 34453165) [PMID:34453165](https://pubmed.ncbi.nlm.nih.gov/34453165/)
- Cited evidence (PMID 24247733) [PMID:24247733](https://pubmed.ncbi.nlm.nih.gov/24247733/)

Last reconciled with current guidelines: 2026-05-15.
References
  • Baddour AHA Infective Endocarditis 2015 (PMID 26373316); Delgado ESC Endocarditis 2023 update (PMID 37622660); Otto ACC/AHA 2020 valvular heart disease guideline (PMID 33342587); Wang JAMA 2014 — early surgery in IE survival benefit (PMID 24247733); Estévez-Loureiro JACC 2024 IREMMI registry (PMID 36440867); SCAI 2022 CS staging (Naidu PMID 35718438) — PMID:26373316
  • Cited evidence (PMID 37622660) — PMID:37622660
  • Cited evidence (PMID 33342587) — PMID:33342587
  • Cited evidence (PMID 34453165) — PMID:34453165
  • Cited evidence (PMID 24247733) — PMID:24247733