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In-Hospital and 1-Year Mortality in Patients Undergoing Early Surgery for Prosthetic Valve Endocarditis
Study Questions:
What are the in-hospital and 1-year survival statistics among patients who undergo early surgery versus medical therapy for prosthetic valve endocarditis (PVE)?
Methods:
Participants were enrolled between June 2000 and December 2006, in the International Collaboration on Endocarditis–Prospective Cohort Study (ICE-PCS), a prospective, multinational, observational cohort of patients with infective endocarditis. Patients hospitalized with definite right- or left-sided PVE were included in the analysis. The effect of treatment assignment on mortality was evaluated after adjusting for biases using a Cox proportional hazards model that included inverse probability of treatment weighting and surgery as a time-dependent covariate. The cohort was stratified by probability (propensity) for surgery, and outcomes were compared between the treatment groups within each stratum.
Results:
Of 1,025 patients with PVE, 490 (47.8%) underwent early surgery and 535 (52.2%) received medical therapy alone. Compared with medical therapy, early surgery was associated with lower in-hospital mortality both in the unadjusted analysis and after controlling for treatment selection bias (in-hospital mortality: hazard ratio [HR], 0.44; 95% confidence interval [CI], 0.38-0.52) and lower 1-year mortality: HR, 0.57; 95% CI, 0.49-0.67). The lower mortality associated with surgery did not persist after adjustment for survivor bias (in-hospital mortality: HR, 0.90; 95% CI, 0.76-1.07 and 1-year mortality: HR, 1.04; 95% CI, 0.89-1.23). Subgroup analysis revealed a lower in-hospital mortality with early surgery in the highest surgical propensity quintile (21.2% vs. 37.5%, p = 0.03). At 1-year follow-up, a lower mortality with surgery was observed in the fourth (24.8% vs. 42.9%, p = 0.007) and fifth (27.9% vs. 50.0%, p = 0.007) quintiles of surgical propensity.
Conclusions:
PVE remains associated with a high 1-year mortality rate. After adjustment for differences in clinical characteristics and survival bias, early valve replacement was not associated with lower mortality compared with medical therapy in the overall cohort. The authors suggested that further studies are needed to define the effect and timing of surgery in patients with PVE who have indications for surgery.
Perspective:
Both native valve and prosthetic valve infective endocarditis are serious infections that are associated with substantial morbidity and mortality. Among patients with native valve infective endocarditis, there is a growing interest in earlier surgical intervention, potentially allowing greater tissue preservation and a higher likelihood of successful valve repair (especially in the setting of mitral valve endocarditis). Using registry data that include both early postoperative and later prosthetic valve endocarditis and statistical propensity matching, this study suggests that early repeat valve replacement was not associated with any lower mortality than was initial medical therapy and later surgical intervention. With mortality no different between earlier and later interventions, a more traditional approach to treating prosthetic valve infective endocarditis might be reasonable, including a longer interval of initial antibiotic therapy to try to minimize re-infection risk at the time of repeat surgery.
Keywords: Survivors, Incidence, Heart Valve Prosthesis, Follow-Up Studies, Hospital Mortality, Heart Valve Diseases, Cardiovascular Diseases, Endocarditis, Bacterial, Tissue Preservation
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