Early Surgery Versus Conventional Treatment for Infective Endocarditis

Study Questions:

Is early surgery preferential to conventional therapy for the treatment of infective endocarditis (IE)?

Methods:

In a prospective trial that enrolled patients at two medical centers in Korea, patients with left-sided IE, severe valve disease, and large vegetations (>15 mm diameter) were randomly assigned to early surgery (37 patients) or conventional treatment (39 patients). The primary endpoint was a composite of in-hospital death and embolic events that occurred within 6 weeks after randomization.

Results:

All patients assigned to the early-surgery group underwent valve surgery within 48 hours after randomization, whereas 30 patients (77%) in the conventional-treatment group underwent surgery during the initial hospitalization (27 patients) or during follow-up (three patients). The primary endpoint occurred in one patient (3%) in the early-surgery group compared with nine patients (23%) in the conventional-treatment group (hazard ratio [HR], 0.10; 95% confidence interval [CI], 0.01-0.82; p = 0.03). There was no significant difference in all-cause mortality at 6 months in the early-surgery and conventional-treatment groups (3% and 5%, respectively; HR, 0.51; 95% CI, 0.05-5.66; p = 0.59). The rate of the composite endpoint of death from any cause, embolic events, or recurrence of IE at 6 months was 3% in the early-surgery group and 28% in the conventional-treatment group (HR, 0.08; 95% CI, 0.01-0.65; p = 0.02).

Conclusions:

Compared with conventional treatment, early surgery in patients with IE and large vegetations significantly reduced the composite endpoint of death from any cause and embolic events by effectively decreasing the risk of systemic embolism.

Perspective:

Observational data suggest that certain features confer higher embolic risk among patients with left-sided IE, including large vegetations, mobile vegetations, and mitral as opposed to aortic vegetations. In addition, there is increasing sentiment among cardiac surgeons to intervene sooner among patients with mitral valve IE in order to minimize tissue destruction and maximize the probability of successful repair as opposed to valve replacement. Data from this prospective trial suggest that embolic risk associated with left-sided IE is lower with earlier intervention. Presumably, this should not be taken to suggest that IE is a primarily surgical disease. Rather, this study provides important new data that support intervention prior to completion of (but not necessarily prior to administration of some) antibiotic therapy.

Keywords: Republic of Korea, Endocarditis, Recurrence, Follow-Up Studies, Membrane Proteins, Cardiovascular Diseases, Confidence Intervals, Embolism, Endocarditis, Bacterial, Mitral Valve


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