Practice guidelines recommend urgent surgery for patients with infective endocarditis and congestive heart failure due to valvular regurgitation.1,2 How soon for patients with large vegetations and when patients have severe valvular dysfunction (but not yet heart failure) is the question that remains to be answered?
In a recently published article by Kang and colleagues3, the authors sought in a randomized controlled fashion to address the timing controversy in this difficult group, therefore those patients with large vegetations and valvular dysfunction but without urgent indications for surgery.
A total of 76 patients with left-sided, native-valve infective endocarditis (defined according to the modified Duke criteria), vegetations with a diameter greater than 10 mm, and severe valvular dysfunction were randomized to early surgery (within 48 hours, n=37) after enrollment or to antibiotic therapy (conventional treatment, n=39). The primary end point was a composite of embolic events or death within 6 weeks after randomization and the secondary end points were embolic events, recurrent endocarditis, repeat hospitalization due to the development of congestive heart failure, or death from any cause at 6 months of follow-up.
The authors demonstrated that all patients who were assigned to surgery underwent valvular surgery while only 30/39 (77%) of patients in the conventional-treatment group underwent surgery. The primary end point occurred in one patient in the early surgery group compared to nine patients in the conventional-treatment group (hazard ratio (HR), 0.10; 95% CI: 0.01 to 0.82; p= 0.03). All-cause mortality was not different between the two groups (3% and 5%, respectively; HR 0.51; 95% CI: 0.05 to 5.66; P = 0.59). The rate of the composite end point of death from any cause, embolic events, or recurrence of infective endocarditis at 6 months was 3% in the surgery group and 28% in the conventional-treatment group (HR 0.08; 95% CI: 0.01 to 0.65; P = 0.02).
This study shows that the benefits of early-surgery for patients with infective endocarditis with large vegetations and severe valvular dysfunction, even if they do not have congestive heart failure might outweigh the additional risk of surgery in patients with active infection.
1. Habib G, Hoen B, Tornos P, et al. Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009): the Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of the European Society of Cardiology (ESC): endorsed by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and the International Society of Chemotherapy (ISC) for Infection and Cancer. Eur Heart J 2009;30:2369-413.
2. Baddour LM, Wilson WR, Bayer AS, et al. Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America. Circulation ...