Aorto-cavitary fistulae in infective endocarditis: understanding a rare complication through collaboration.

This editorial refers to ‘Aorto-cavitary fistulous tract formation in infective endocarditis: clinical and echocardiographic features of 76 cases and risk factors for mortality’† by I. Anguera et al. , on page 288 Even in the modern era of antimicrobial chemotherapy and advanced diagnostic imaging, infective endocarditis continues to surprise, frustrate, and perplex, and remains an evolving disease with a persistently high mortality and morbidity. Almost all aspects of the disease, including its natural history, pre-disposing factors, sequelae, and causative organisms are virtually unrecognizable compared with Osler's initial descriptions from the nineteenth century.1 In particular, chronic rheumatic heart disease is now an uncommon antecedent, whereas mitral valve prolapse, prior valve replacement, intravenous drug use, and preceding vascular instrumentation have become increasingly frequent, coinciding with an increase in staphylococcal infections and those due to fastidious or atypical organisms.2 Clinical studies have been slow to adapt to these shifting epidemiological patterns, partly on account of the relative scarcity of infective endocarditis, contemporary series indicating a current incidence of 1.7–6.2 cases per 100 000 patient years.3 Knowledge of the clinical features and natural history of the disease has therefore relied largely on small, uncontrolled, outdated studies; modern, well-designed studies reflecting current disease patterns are long overdue. Anguera et al. 4 report a large case series of 76 patients with surgically or autopsy proven aorto-cavitary fistulous tract formation, identified from a multi-centre clinical database of infective endocarditis over a 10 year period. Previously, … *Corresponding author. Tel: +44 161 291 2923; fax: +44 161 291 2389. E-mail address : bernard.prendergast{at}smuht.nwest.nhs.uk