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Association Between Valvular Surgery and Mortality Among Patients With Infective Endocarditis Complicated by Heart Failure
Study Questions:
What are the predictors of in-hospital and 1-year mortality among patients with native- or prosthetic-valve infective endocarditis and heart failure (HF)?
Methods:
The International Collaboration on Endocarditis–Prospective Cohort Study is a prospective, multicenter study enrolling 4,166 patients with definite native- or prosthetic-valve infective endocarditis from 61 centers in 28 countries between June 2000 and December 2006. Clinical, echocardiographic, and microbiological variables among patients with infective endocarditis and HF were examined for predictors of in-hospital and 1-year mortality.
Results:
Of 4,075 patients with infective endocarditis and known HF status, 1,359 (33.4%; 95% confidence interval [CI], 31.9%-34.8%) had HF, and 906 (66.7%; 95% CI, 64.2%-69.2%) had New York Heart Association class III or IV symptoms. Within the subset with HF, 839 (61.7%; 95% CI, 59.2%-64.3%) underwent valve surgery during the index hospitalization. In-hospital mortality was 29.7% (95% CI, 27.2%-32.1%) for the entire HF cohort, with lower mortality observed in patients undergoing valve surgery compared with medical therapy alone (20.6%; 95% CI, 17.9%-23.4% vs. 44.8%; 95% CI, 40.4%-49.0%, respectively; p < 0.001). One-year mortality was 29.1% (95% CI, 26.0%-32.2%) in patients undergoing valve surgery vs. 58.4%; 95% CI, 54.1%-62.6%) in those not undergoing surgery (p < 0001). Cox proportional hazards modeling with propensity score adjustment for surgery showed that advanced age, diabetes mellitus, health care–associated infection, causative microorganism (Staphylococcus aureus or fungi), severe HF (New York Heart Association class III or IV), stroke, and paravalvular complications were independently associated with 1-year mortality, whereas valve surgery during the initial hospitalization was associated with lower mortality.
Conclusions:
In this cohort of patients with infective endocarditis complicated by HF, severity of HF was strongly associated with surgical therapy and subsequent mortality, and valve surgery was associated with lower in-hospital and 1-year mortality.
Perspective:
HF is an indication for surgical intervention in any patient with any left-sided regurgitant heart valve lesion, including patients with regurgitation resulting from infective endocarditis. This large multicenter study confirms that advanced HF is associated with an adverse prognosis among patients with infective endocarditis, and that surgical intervention during the initial hospitalization is associated with mitigation of risk.
Keywords: Prognosis, Endocarditis, Hospital Mortality, Staphylococcal Infections, Heart Failure, Staphylococcus aureus, Hospitalization, Heart Valves
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