Delays cost lives: prognostic impact of echocardiographic timing in patients with infective endocarditis

Abstract Background Timely diagnosis of infective endocarditis (IE) is crucial for improving clinical outcomes. Transthoracic (TTE) and transesophageal echocardiography (TEE) are essential imaging modalities in the diagnostic work-up. However, the prognostic implications of delayed imaging remain unclear. Purpose This study aimed to assess the impact of TTE and TEE timing on total mortality—including both in-hospital and long-term mortality—in patients with IE. Methods This retrospective cohort study included 165 patients with definite IE who underwent both TTE and TEE. Patients were categorized into three groups based on echocardiographic timing: (1) both TTE and TEE performed within 3 days of admission, (2) early TTE with delayed TEE, and (3) both modalities delayed beyond 3 days. The primary outcome was total mortality. Cox proportional hazards regression was used to identify independent predictors of mortality. Model performance was evaluated using ROC curves, and survival outcomes were compared with Kaplan–Meier analysis. Results Total mortality occurred in 84 patients (50.9%), with 70.2% of deaths (59 patients) occurring during hospitalization. Delayed evaluation with both TTE and TEE (>3 days) was significantly associated with increased total mortality (HR: 2.036; 95% CI: 1.319-3.142; p = 0.001), whereas early TTE combined with delayed TEE was associated with an intermediate survival (HR: 0.480; 95% CI: 0.282–0.818; p = 0.007) ( Figure 1). In multivariate analysis, advance age (HR: 1.018; 95% CI: 1.003-1.032; p = 0.016), increased NYHA class (HR: 1.591; 95% CI: 1.306-1.938; p < 0.001), peak CRP/albumin ratio (HR: 1.088; 95% CI: 1.026-1.153; p = 0.005), delayed echocardiographic evaluation (HR: 1.660; 95% CI: 1.063-2.592; p = 0.026) were independent predictors of mortality (Table -1). ROC analysis showed excellent model discrimination (AUC = 0.820), with a sensitivity of 78.57% and specificity of 71.60 % (Figure 2). Kaplan–Meier curves confirmed significantly reduced survival in patients with delayed imaging (Figure 1). Conclusion Delayed echocardiographic assessment, particularly when both TTE and TEE are postponed beyond 3 days, is associated with increased mortality in IE patients. Early performance of at least one imaging modality may provide a survival benefit. Prompt echocardiographic evaluation should be considered a key component of initial IE management.Table 1 Figure 1 and Figure 2