CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 2, May/June 2023 AFRICA 87 complication, followed by acute renal failure (17.7%) and heart failure (14.1%).18 In our study, surgery was indicated in 91.11% of patients and it was performed in only 28.89%. The most common cause of failure to perform surgery was the death of patients before surgery (30%), followed by patient refusal (18.89%). In-hospital mortality was 34.44% and the most common cause was combined cardiogenic and septic shock. The mean duration of survival from admission to death was 19.19 ± 10 days with a range of five to 53 days. In the study by Zahn et al., surgery was indicated in 81.1% of patients and the in-hospital mortality rate was 21.6%, with no difference in mortality rate between those who were operated on versus those who were treated conservatively.23 Blanchard et al. reported that 69% of their patients had a theoretical indication for surgery but surgery was performed in only 52%. They reported a mortality rate of 37%, including pre- and post-operative deaths.19 Babic et al. reported that surgery was recommended in 67.4% of patients and it was performed in only 34.7% of patients. The reasons behind those who did not undergo surgical intervention were: patient refusal, surgeon rejection and poor clinical condition. The in-hospital mortality rate was reported to be 33.7%.22 El Kadi et al. reported that surgery was done as indicated in 50.4% of the included patients. The in-hospital mortality rate was 14.4% and the median time was 30 days, with a range of 14 to 48 days. In-hospital mortality did not differ significantly between surgically and conservatively treated patients (12.9 vs 15.9%, p = 0.391).20 Acibuca et al. reported that the in-hospital mortality rate was 30.2% and in a regression analysis, chronic renal disease, congestive heart failure and chronic dialysis were found to be associated with an increased mortality risk.21 Habib et al. reported that surgery was indicated in 69.3% of the included patients but it was performed in only 51.2%. In-hospital death occurred in 17.1% of patients and it was higher in prosthetic valve IE than in other groups.18 In the current study, a one-year follow up showed an 8.47% mortality rate, 11.86% re-admission for heart failure and 6.78% had a re-do surgery either due to re-infection or on top of valve thrombosis. None of the above studies had long-term follow up but Habib et al. reported that long-term follow-up data, including events occurring during the first year, will be assessed in future ancillary studies of their registry.18 Tahon et al. published a retrospective study in 2021 on 270 patients with an IE diagnosis and followed them up to 10 years. They reported a mortality rate of 28.9% at one year. This percentage is relatively higher than our data but this may be related to the higher in-hospital mortality rate we had in our study.24 There are limitations to this study. It was a single-centre study, and despite the large number of patients included, we cannot say that this is a true population-based sample. This was an observational study of patients from a tertiary-care university hospital where only complex cases of IE are referred. Therefore, data from other centres may differ completely due to the nature of the patients included. Conclusions IE nowadays tends to affect a younger group of patients, and valvular heart disease is the main underlying condition. IV drug use is becoming the main risk factor for endocarditis in developing countries. Negative blood cultures are frequently encountered due to misuse of antibiotics, with many resistant strains such as MRSA in positive cultures. Despite the availability of surgery and numerous antimicrobials, the mortality rate due to IE is high in developing countries. The effects of IE are not only immediate and short-term complications, but can extend for a longer period of time. References 1. Tleyjeh IM, Abdel-Latif A, Rahbi H, Scott CG, Bailey KR, Steckelberg JM, et al. A systematic review of population-based studies of infective endocarditis. Chest 2007; 132(3): 1025–1035. 2. Siegman-igra Y, Koifman B, Porat R, Porat D, Giladi M. Healthcare associated infective endocarditis: A distinct entity. Scand J Infect Dis 2008; 40(6-7): 474–480. 3. 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