RiskE Score for Cardiac Surgery in Active Infective Endocarditis

Why did you develop the RiskE Score? Was there a particular clinical experience or patient encounter that inspired you to create this tool for clinicians?

Infective endocarditis is a serious disease that requires surgery in nearly half of the cases. The endocarditis team should decide the indication and timing for cardiac surgery, but there was a lack of tools to help make this decision and select patients who would benefit the most from surgery.

Surgical scores are widely used in cardiology to select the best strategy in valve heart disease or coronary revascularization. However, these scores were neither specific nor accurate for infective endocarditis.

The RiskE Score was developed to help clinicians and endocarditis teams to estimate the surgical risk in this particular type of patients.

What pearls, pitfalls and/or tips do you have for users of the RiskE Score? Do you know of cases when it has been applied, interpreted, or used inappropriately?

The RiskE Score is a helpful tool in estimating the postoperative mortality in patients with active left-sided endocarditis. This score has been internally and externally validated, and performs better than other existing surgical scores. However, it should never replace clinical criteria and expertise of the endocarditis team.

In addition, it has been developed in patients with left-sided active infection. Thus, it should not be used in patients with isolated right-sided endocarditis or once the active infection has been treated and healed.

What recommendations do you have for doctors once they have applied the RiskE Score? Are there any adjustments or updates you would make to the score based on new data or practice changes?

Once the RiskE Score has been applied and clinicians have an estimation of the predictive in-hospital postoperative mortality, other clinicals factors should be taken into account when deciding the risk-benefit balance of surgery. Surgical scores do not replace clinical judgment.

Moreover, important clinical factors such as hemorrhagic stroke or pulmonary hypertension, which are relevant prognostic factors in cardiac surgery, should also be taken into consideration.

Finally, several variables included in the score (cardiogenic shock, thrombocytopenia, septic shock) can be modifiable, so the estimated risk of a patient may vary if these factors can be adequately controlled before surgery.

How do you use the RiskE Score in your own clinical practice? Can you give an example of a scenario in which you use it?

We now apply the RiskE Score in all our patients with endocarditis because it provides an estimation of the individual surgical risk.

We consider the RiskE Score an additional tool that helps us in deciding the risk/benefit balance and the timing for surgery.

Carmen Olmos, MD, is a clinical cardiologist at Hospital Clínico San Carlos in Madrid, Spain. She is also a researcher in the Endoval group. Dr. Olmos’ primary research is focused on cardiomyopathies, valve heart disease, and infective endocarditis.