Perspective:

In this retrospective, registry-based study, larger vegetation size was associated with worse 6-month mortality only among patients who did not undergo early surgery (during the index hospitalization and before the completion of antibiotic therapy); larger vegetation size was not associated with higher mortality among patients who underwent early surgery. However, compared to surgically treated patients with a large vegetation, medically treated patients with a large vegetation were older, and almost without exception had increased rates of comorbidities and predictors of adverse outcome (higher rates pf diabetes, stroke, heart failure, atrial fibrillation/flutter, coronary artery disease, prior coronary artery bypass grafting, chronic obstructive pulmonary disease, advanced kidney and liver disease, cancer, prosthetic valve IE, and infection with Staphylococcus aureus or fungi). Patients who underwent early surgery had higher rates of accepted indications for early surgery, including paravalvular complications, persistent bacteremia, and embolic events. It is difficult to extrapolate these data to suggest that early surgery is the independent cause of lower mortality, rather than a statistical association.