Clinical Profile of a Series of Left-Sided Prosthetic Valve Endocarditis: Revisiting Surgical Indications

<b>Background/Objectives:</b> Prosthetic valve endocarditis (PVE) carries a high morbidity and mortality. Surgery is classically indicated for heart failure, uncontrolled infection, or prevention of embolic events; however, evidence supporting surgery for "non-classical" indications-such as <i>Staphylococcus aureus</i> infection, non-HACEK Gram-negative bacteria, or early PVE-remains limited. This study aimed to update the clinical and prognostic profile of PVE and assess the impact of surgery, particularly in patients with non-classical surgical indications. <b>Methods</b>: We prospectively included all definite left-sided PVE cases diagnosed between 2000 and 2024 at three tertiary centers. Clinical, microbiological, echocardiographic, and prognostic data were analyzed and compared. Predictors of in-hospital mortality were identified using multivariable logistic regression, and Kaplan-Meier curves were used to compare 1-year survival according to surgical indications. <b>Results</b>: Among 589 patients with left-sided PVE, 61% underwent surgery, and in-hospital mortality was 31%. Independent mortality predictors were chronic obstructive pulmonary disease, pulmonary hypertension, periannular complications, <i>S. aureus</i> infection, and poor clinical condition at admission. Non-classical surgical indications were present in 38% of patients, although only 28 (5%) of them had no other surgical indication. These patients exhibited lower mortality (14%) and no survival benefit from surgery (10% vs. 17%; <i>p</i> 0.999). <b>Conclusions</b>: PVE remains associated with high mortality. Surgery improves survival in patients with classical surgical indications but not in patients with non-classical indications, supporting individualized surgical decisions by a multidisciplinary endocarditis team.