Early Surgery For Infective Endocarditis Research Articles

Abstract 14886: Outcome of Early Surgery in Active Infective Endocarditis in Terms of Intraoperative Valve Culture

Introduction: In recent years, the benefit of early surgery in active infective endocarditis (IE) has been reported. The drawback of early surgery is the risk that residual bacteria in the operative field may cause IE recurrence. Little is known regarding the relationship between intraoperative valve culture and recurrence. In the present study, we investigated the value of early surgery for IE based on the results of valve cultures. Hypothesis: Positive intraoperative valve cultures in early surgery are associated with recurrence. Methods: Between 2009 and 2017, 585 patients underwent valve surgery for definitive left-sided active IE at 14 affiliated hospitals. Early surgery was defined as surgery within 14 days from diagnosis, and patients with unknown valve culture results were excluded. We analyzed the short and mid-term outcome in patients with early surgery (n=228). These 228 patients were compared in two groups: positive (Group P, n=106) and negative (Group N, n=122) valve cultures. The primary outcome was all-cause mortality. Secondary outcomes were recurrence of IE. Mean follow-up time was 2.5±2.8 years. Results: Patients in group P had a significantly higher inflammatory response on preoperative blood tests (White blood cell count: 10.4 (8.3-14.5) vs. 8.2 (6.0-12.7) х10 3 /μl, p=0.005, C-reactive protein: 7.3 (3.8-11.0) vs. 3.8 (2.1-6.8) mg/dl, p<0.001). Patients in group P also had a significantly shorter duration from diagnosis to surgery (2 (1-4) vs. 4 (1-9) days, p<0.001). There was no significant difference in in-hospital mortality between the two groups (13/106 (12%) vs. 11/122 (9%), p=0.43). The overall survival rate at 1 and 5 years was 83% and 69% in group P, 82% and 75% in group N, respectively (p=0.85). The rate of freedom from the recurrence of endocarditis at 1 and 5 years postoperatively was 97% and 82% in group P, and 98% and 92% in group N, respectively (p=0.02). In Cox's hazard analysis, positive valve culture was a risk factor for IE recurrence in multivariate analysis (hazard ratio, 3.39; 95% confidence interval, 1.07 to 10.67; p=0.037). Conclusions: Positive valve culture cases in early surgery for active IE have a significantly increased risk of recurrence compared with valve culture-negative cases and require careful management.

Endocarditis-related stroke is not a contraindication for early cardiac surgery: an investigation among 440 patients with left-sided endocarditis.

A treatment dilemma arises when surgery is indicated in patients with infective endocarditis (IE) complicated by stroke. Neurologists recommend surgery to be postponed for at least 1 month. This study aims to investigate the neurological complication rate and neurological recovery potential in patients with IE-related stroke. A total of 440 consecutive patients with left-sided IE undergoing surgery were investigated. During follow-up, neurological recovery was assessed using the modified Rankin scale and the Barthel index. Mortality was assessed with regression models adjusting forage. The median follow-up time was 9.0 years. Patients with previous strokes were more likely to suffer from mitral valve endocarditis (29.5% vs 47.4%, P < 0.001). Symptomatic stroke was found in 135 (30.7%) patients; of them, 42 patients presented with complicated stroke (additional meningitis, haemorrhagic stroke or intracranial abscess). Driven by symptomatic stroke, the age-adjusted hospital mortality risk was 1.4-fold [95% confidence interval (CI) 0.74-2.57; P = 0.31] higher and the long-term mortality risk was 1.4-fold higher (95% CI 1.003-2.001; P = 0.048). Hospital mortality was higher in patients with complicated stroke (21.4% vs 9.7%; P = 0.06) only; however, mortality rates were similar comparing uncomplicated stroke versus no stroke. Among patients with complicated ischaemic strokes, the observed risk for intraoperative cerebral haemorrhage was 2.3% only and the increased hospital mortality was not driven by cerebral complications. In the long-term follow-up, full neurological recovery was observed in 84 out of 118 survivors (71.2%), and partial recovery was observed in 32 (27.1%) patients. Neurological recovery was lower in patients with complete middle cerebral artery stroke compared to other localization (52.9% vs 77.6%; P = 0.003). Contrary to current clinical practice and neurological recommendations, early surgery in IE is safe and neurological recovery is excellent among patients with IE-related stroke. UN4232 382/3.1 (retrospective study).

Early surgery with aggressive surgical approach to improve 6-month outcomes in patients with active infective endocarditis: contribution of cerebral preoperative magnetic resonance imaging.

We investigated the hypothesis that early surgery for infective endocarditis (IE) attenuates the rate of death or embolic events and does not increase the rate of relapse or postoperative valvular dysfunction (PVD) at 6 months. 21 consecutive patients who underwent surgical treatment of IE were prospectively included. We assessed 6-month postoperative clinical outcomes by comparing early surgery (Group E, surgery within 72h) and conventional treatment (Group C). Nine patients (43%) were assigned to Group E based on a combination of preoperative evaluation parameters, including the findings of cerebral magnetic resonance imaging (MRI), which was performed in all patients with left-sided IE. Six surgical plans (5 advancements and 1 postponement) were modified by routine MRI. Although preoperative echocardiography did not confirm all annular invasions, the rate of periannular infection, which was treated by pericardial annular patch plasty (56%) in patients with native-valve IE, was higher in Group E than C (P = 0.006). Early surgery based on MRI findings resulted in no postoperative embolic events or cerebral bleeding. The 6-month mortality rate was 0% in both groups, although the calculated 6-month IE mortality rate was 49.2 ± 25% and 28.8 ± 18%, respectively. No recurrence of IE or PVD occurred in Group E. The 6-month rate of freedom from composite events was 100% in Group E. Aggressive treatment (periannular resection and disuse of a prosthetic annuloplasty ring) and optimal antibiotic therapy based on intraoperative microorganisms, even in patients who underwent early surgery, reduced the 6-month relapse and PVD rates.

Effect of the Initial Strategy for Active Endocarditis Complicated With Acute Heart Failure

Early surgery for infective endocarditis (IE) with acute heart failure (AHF) is recommended, despite clinical results being unclear. We investigated the effect of initial treatment in such patients. Methods and Results: Outcomes for 470 patients with active IE who underwent valvular surgery during 2009-2016 were reviewed. Of them, 177 had symptomatic AHF when diagnosed with IE (excluding those with cardiogenic shock or intubated for AHF). They were divided into 2 groups based on initial treatment: Group S (underwent valvular surgery immediately; n=74) and Group M (received initial medical treatment for infection and HF; n=103). The median (interquartile range) waiting period from diagnosis to surgery in Groups S and M was 1 (1-3) and 15 (8-33) days, respectively (P<0.001). The 5-year survival rate was higher in Group S than Group M (80% vs. 64%; P=0.108). Group M was divided into Group P (initial medical treatment was effective and elective surgery was performed; n=62) and Group E (emergency surgery was necessary during medical treatment; n=41); overall 5-year survival was significantly worse in Group E than Group P (42% vs. 79%; P<0.012). In Group M, multivariate analysis indicated that Staphylococcus aureus infection (odds ratio 3.82; 95% confidence interval 1.19-13.3; P=0.024) was a significant risk factor for conversion to emergency surgery. Considering poor outcomes of emergency surgery for medically refractory HF, early surgery may be a reasonable option for IE patients, especially those with S. aureus infection.

Mortality and timing of surgery in the left-sided infective endocarditis: an Italian multicentre study.

Observational studies on early surgery in infective endocarditis have conflicting results. This study aims to compare the treatment strategies for early surgery (within 2 weeks of diagnosis) and late surgery/medical therapy in terms of survival among patients with the left-sided infective endocarditis. This study included patients with the left-sided infective endocarditis registered between 2006 and 2010 in the Italian Registry of Infective Endocarditis (RIEI). A Cox proportional hazards model was used to estimate the effect of these treatment strategies on overall survival and included sociodemographic and clinical characteristics associated with treatment, risk factors for mortality and early surgery as a time-dependent covariate to avoid indication and immortal time biases. Among the 502 patients included, 184 (36.7%) underwent early surgery. Of the remaining 318 patients, 138 underwent late surgery. The early surgery group had fewer patients with comorbidities and with enterococcus as the causative microorganism, but this group had more complicated cardiac conditions. No difference in mortality risk was estimated between the treatment groups including early surgery as time-dependent variables (adjusted hazard ratio = 0.95, 95% confidence interval 0.55-1.63), while a distorted and overestimated beneficial effect of surgery was estimated considering surgery as a non-time-dependent variable (adjusted hazard ratio 0.41, 95% confidence interval 0.25-0.70). Our study did not confirm a better overall survival in patients undergoing early surgery. However, even with the use of statistical techniques to control biases, we could not draw definitive conclusions that early surgery is not beneficial. Our results need to be assessed by randomized trials before any changes in clinical practice can be recommended.

Early Surgery for Infective Endocarditis with Stroke Does Not Increase Post-operative Neurological Complications: What are We Waiting For? (S29.007)

Early Surgery for Infective Endocarditis with Stroke Does Not Increase Post-operative Neurological Complications: What are We Waiting For? (S29.007)

Abstract TMP87: Early Surgery for Infective Endocarditis with Stroke Does Not Increase Post-operative Neurological Complications: What are We Waiting For?

Introduction: Ischemic and hemorrhagic stroke often complicate infective endocarditis (IE). Optimal timing of surgical intervention for IE with stroke remains controversial. We compared neurological outcomes of early and delayed valve surgery for IE complicated by stroke. Methods: We reviewed 73 patients with acute IE by Duke Criteria who underwent brain imaging (CT, MRI, or cerebral angiogram) before valve operations between December 2014 and August 2016. Date of IE diagnosis was defined as date of antibiotic initiation. Early surgery was defined as valve replacement ≤14 days from date of IE diagnosis and delayed surgery as &gt;14 days. Neurological complication is defined as delirium &gt;72 hours after extubation and cessation of sedation, new ischemic or hemorrhagic stroke. Results: Among 73 patients who underwent valve replacement surgery, 71 had evidence of stroke on imaging: 54 patients with acute or subacute ischemic infarct, 9 patients with evidence of intracerebral hemorrhage, and 8 patients with subarachnoid hemorrhage. The median time from IE diagnosis to surgery was 9 days. Forty patients had early surgery, and 33 patients had late surgery. Early surgery group had fewer patients with history of ischemic stroke (55% vs 79%, p=0.033), fewer acute or subacute infarcts on imaging (63% vs 88% p=0.016), but more native valve infections (73% vs 45%, p=0.018). The incidence of post-operative stroke was similar between both groups (2.5% vs 9%, p=0.32). In the delayed group, ischemic strokes occurred in 4 patients awaiting surgery. Hypertension and diabetes mellitus were associated with post-operative neurological complications (p&lt;0.05), but pre-operative stroke on imaging was not. Conclusion: In IE patients with acute stroke, early surgery does not appear to increase post-operative neurological complications.

Neurologic outcomes after early surgery for infective endocarditis in patients with combined cerebral septic embolism.

This study followed the results of any development of neurologic outcomes according to the presence or absence of cerebral stroke in infective endocarditis patients after early cardiac surgery. We also analysed the neurologic outcomes regardless of cerebral microbleeds in cerebral embolic patients after cardiac surgery. We retrospectively studied 55 patients with left-sided infective endocarditis who underwent early surgery and hospitalization between May 2010 and May 2015. Preoperatively, there were 33 patients in the cerebral embolic group and 22 patients in the non-embolic event group. Among the cerebral embolic patients, 13 patients had additional cerebral microbleeds on brain imaging. After cardiac surgery, intracranial haemorrhage and haemorrhagic complications occurred in 2 patients (9.1%) in the non-embolic group and 5 patients (15.1%) in the embolic group. There was no statistically significant difference in postoperative neurologic problems between the non-embolic group and the embolic group (22.7% vs 30.3%, respectively, P = 0.54). Early mortality was 4.5% in the non-embolic group and 9.1% in the embolic group ( P = 1.00). In the cerebral microbleeds combined with septic embolism group, the neurologic problem rate (38.5%) was higher than in the non-cerebral microbleeds group (20.0%), but the difference was not statistically significant. Our analysis showed that the rate of postoperative neurologic problems was not high in patients with cerebral septic embolism. Despite this, early surgery is not contraindicated in cerebral septic emboli patients. Cerebral microbleeds related to septic embolism were suspected to increase the rate of neurologic problems after cardiac surgery. So, further studies are needed to assess about the influence of cerebral microbleeds in cardiac operation.

Early surgery in infective endocarditis: Why should we wait?

Early surgery in infective endocarditis: Why should we wait?

Outcomes of early surgery for infective endocarditis with moderate cerebral complications

ObjectivesWe sought to clarify the effect of stroke severity on clinical outcomes in patients with infective endocarditis (IE) with cerebral complications and evaluate the impact of early surgery in the active phase on long-term prognosis in patients with nonsevere neurologic deficits. MethodsClinical data were reviewed retrospectively in 170 consecutive patients with active left-sided IE with cerebral complications from 1990 to 2014. The mean age was 60 ± 17 years, and 93 (55%) were men. The National Institutes of Health Stroke Scale (NIHSS) was used to evaluate the severity of stroke. Major adverse cardiac events were defined as a composite of IE-related death, repeat surgery, and recurrence of IE. ResultsBaseline NIHSS score was associated strongly with clinical outcome. When patients were divided into 2 groups according to NIHSS, 33 patients had severe stroke (NIHSS ≥11) and 137 had nonsevere stroke (NIHSS ≤10); freedom from IE-related death and major adverse cardiac events was significantly lower in patients with severe stroke than in those with nonsevere stroke. Of 137 patients with nonsevere stroke, 65 underwent early surgery within 2 weeks of onset, and conventional treatment was applied in 72. Freedom from IE-related death was significantly greater in patients undergoing early surgery than in those on conventional treatment (P = .007). Moreover, adjusted survival analysis using the inverse probability treatment weighting method showed a significant beneficial effect of early surgery in reducing IE-related death (P = .012) in patients with nonsevere stroke. ConclusionsEarly surgery might be beneficial in patients with nonsevere stroke.

Valvular disease: Benefit of early surgery for infective endocarditis.

Valvular disease: Benefit of early surgery for infective endocarditis.

Optimal timing for early surgery in infective endocarditis: a meta-analysis.

To systematically review early surgery and the optimal timing of surgery in patients with infective endocarditis (IE), a search for foreign and domestic articles on cohort studies about the association between early surgery and infective endocarditis published from inception to January 2015 was conducted in the PubMed, EMBASE, Chinese Biomedical Literature (CBM), Wanfang and Chinese National Knowledge Infrastructure (CNKI) databases. The studies were screened according to the inclusion and exclusion criteria, the data were extracted and the quality of the method of the included studies was assessed. Then, the meta-analysis was performed using the Stata 12.0 software. Sixteen cohort studies, including 8141 participants were finally included. The results of the meta-analysis revealed that, compared with non-early surgery, early surgery in IE lowers the incidence of in-hospital mortality [odds ratio (OR) = 0.57, 95% confidence interval (CI) (0.42, 0.77); P = 0.000, I(2) = 73.1%] and long-term mortality [OR = 0.57, 95% CI (0.43, 0.77); P = 0.001, I(2) = 67.4%]. Further, performing operation within 2 weeks had a more favourable effect on long-term mortality [OR = 0.63, 95% CI (0.41, 0.97); P = 0.192, I(2) = 39.4%] than non-early surgery. In different kinds of IE, we found that early surgery for native valve endocarditis (NVE) had a lower in-hospital [OR = 0.46, 95% CI (0.31, 0.69); P = 0.001, I(2) = 73.0%] and long-term [OR = 0.57, 95% CI (0.40, 0.81); P = 0.001, I(2) = 68.9%] mortality than the non-early surgery group. However, for prosthetic valve endocarditis (PVE), in-hospital mortality did not differ significantly [OR = 0.83, 95% CI (0.65, 1.06); P = 0.413, I(2) = 0.0%] between early and non-early surgery. We concluded that early surgery was associated with lower in-hospital and long-term mortality compared with non-early surgical treatment for IE, especially in NVE. However, the optimal timing of surgery remains unclear. Additional larger prospective clinical trials will be required to clarify the optimal timing for surgical intervention and determine its efficacy in PVE.

EComment. Early surgery in preventing stroke in left-sided infective endocarditis

I read with great interest the article by Okonta et al. [1], and I think that the discussion should be primarily focused on early surgery in left-sided infective endocarditis (IE) to prevent stroke. The three main indications for early surgery in IE are heart failure, uncontrolled infection and prevention of embolic events [2]. Although embolic stroke is a major cause of morbidity in patients with IE, the value of early surgery in preventing embolic events still remains controversial. According to the data analyzed by Okonta et al. [1], it is very clear that a vegetation length >10 mm and severe vegetation mobility are the most potent independent predictors of a embolic event. If we use the term new embolic event in relation to the time after the beginning the antibiotic therapy in IE, then the benefits of surgery in preventing embolism may be greatest during the first week of antibiotic therapy. This is because the risk of embolism is highest during the first days following the initiation of antiobiotic therapy and decreases two weeks thereafter [3]. Although recommendations of European Society of Cardiology guidelines for IE emphasize the timing of surgery [2], the exact role of early surgical intervention in order to avoid embolic events is still unclear. Vegetation size can be one of the reasons for surgery, but is rarely the only one. In the absence of a previous embolism, surgery is indicated with vegetation length >10 mm and some other predictor of complicated IE (heart failure, uncontrolled infection). Eventually, surgery may be considered in cases with very large (>15 mm) vegetations on the aortic or mitral valve, according to the possibility of valve repair. Cabell et al. [4] have demostrated that in native IE, mitral valve IE is associated with higher risk of embolism than aortic valve IE (OR 3.6; 95% CI 1.1-11.6). That is why earlier surgery should be especially emphasized in the cases of mitral valve vegetations. Finally, one must keep in mind that the major complications with early surgery are valve dysfunction because of tissue inflammation, and the increased risk of recurrent infection resulting in early prosthetic valve endocarditis [5]. Any current conclusions must be open to continuing review as data become available to allow more enlightened judgements in preventing the risk of embolism in left-sided IE. Some personal conclusions regarding the indication of early surgery in IE include: i) vegetation lengths >10 mm associated with one of the following conditions: complicated course of IE (haemodynamic deterioration, uncontrolled infection, neurological complication), severe vegetation mobility located on the mitral valve, valve repair appears feasible immediately after antibiotic therapy is started; ii) vegetation length >15 mm in aortic or mitral valve with or without other complication. Conflict of interest: none declared

Early surgery in infective endocarditis with large vegetations significantly reduced mortality compared with conventional treatment

Commentary on: Kang DH, Kim YJ, Kim SH, et al. Early surgery versus conventional treatment for infective endocarditis. N Engl J Med 2012;366 :2466–73.[OpenUrl][1] The treatment of infective endocarditis (IE)...

Clinical predictors of in-hospital death and early surgery for infective endocarditis: Results of CArdiac Disease REgistration (CADRE), a nation-wide survey in Japan

BackgroundThe benefit of early surgery for IE is yet to be determined in non-Western countries. We conducted this study to evaluate the role of early surgery in infective endocarditis (IE) in Japan. MethodsIE admissions in Japan were prospectively registered using a nation-wide WEB-based registration system (CArdiac Disease REgistration, CADRE). The impact of early surgery on in-hospital mortality was assessed in native valve endocarditis (NVE) and prosthetic valve endocarditis (PVE). Risk factors for in-hospital death were assessed by multiple logistic regression analysis. The propensity score for early surgery was calculated to adjust the impact of early surgery. ResultsFrom September 2006 to May 2009, 348 NVE and 81 PVE were registered. In NVE, early surgery was preferable in every quartile stratified with the propensity score and the summary odds ratio (OR) and 95% confidence interval (CI) was 0.12 (0.05–0.31). The predictors of in-hospital death were Staphylococcus aureus infection (OR 3.5, 95% CI 1.26–9.7), heart failure (OR 6.74, 95% CI 2.43–18.7) and early surgery (OR 0.07, 95% CI 0.03–0.2). In PVE, the predictors of in-hospital death were age (OR 1.09, 95% CI 1.01–1.18), S. aureus infection (OR 5.8, 95% CI 1.4–24.01) and heart failure (OR 7.44, 95% CI 1.81–30.67), whereas early surgery was not (OR 0.51, 95% CI 0.12–2.16). ConclusionEarly surgery for NVE is associated with improved survival in a wide range of clinical subgroups in Japan. In PVE a survival benefit of early surgery is not clear.

Chirurgie précoce dans l'endocardite infectieuse. Étude rétrospective à propos de 30 cas

Aim The aim of this study is to stress the interest of the early surgery in infective endocarditis (IE), its indications and prognostic implications. Methods It is a retrospective descriptive study of 30 cases (29 men and 1 woman with an average age of 35 ± 12 years) with IE underwent surgery management in the acute phase between September 1993 and June 2005. Results They were 25 rheumatic lesions, 2 aortic bicuspids and 3 mechanical valves prosthesis. Four twenty-six percent of the patients were operated for hemodynamic deterioration and 10% for embolic complication. We report 3 cases (that is to say 10%) of IE late form on prosthesis. Three patients died in the first post operative month by respectively total desinsertion of mitral prosthesis on peroperative, 1 septic shock at the 13th post operative day and 1 tamponade at the 14th postoperative day. On 72 months an average follow-up, 26 were controlled regularly: 25 evolved favourably and 1 died in third postoperative year (severe heart failure). Conclusion A high early surgery rate is related to good long term results and does not increase in hospital mortality. The reduced mortality was particularly evident among patients with moderate to severe congestive heart failure.

Surgical treatment of infective endocarditis complicated by annular infection and cerebral infarction.

The surgical treatment of nine patients with infective endocarditis (IE) complicated by annular infection and five with IE complicated by cerebral infarction is described herein. In those with annular infection, after thorough débridement of the infected tissues, valve replacement was performed at the original position in five, at the supraannular position in three, and one underwent a translocation procedure. Aortic valve replacement was able to be performed at the original position in two patients by closing the defect at the aortic annulus with a patch after through débridement. The five patients who underwent original valve position replacement recovered well. Of the three who underwent supraannular position replacement, two died of septicemia after a redo operation, and one received pacemaker implantation. The patient undergoing the translocation procedure died of intestinal infarction. In the five patients who suffered cerebral infarction due to embolus of the vegetation, valve replacement was performed between 40 h and 5 months after its onset. Although one patient died of the rapid progression of brain damage, the other four are alive and well, including two who developed mycotic cerebral aneurysm in the infarcted areas. In conclusion, early surgery for IE is mandatory irrespective of active infection, due to the high mortality and morbidity associated with serious sequelae such as annular abscess or cerebral infarction.

Early surgery in infective endocarditis.

Optimal timing of surgical intervention in infective endocarditis is important in reducing mortality. We prospectively studied 126 consecutive episodes of infective endocarditis treated in one institution over 5 years, with special emphasis on long-term results and on the effects on outcome of surgical interventions. Twenty-six patients (21%) underwent acute surgery on median treatment day 14. Mortality during treatment was 8% for patients undergoing acute surgery vs. 11% for those not undergoing surgery, and the adjusted 5-year survival rate of acute surgically treated patients was 91%, compared with 69% for the medically treated patients. Using univariate analysis, excess mortality during 5 years follow-up was associated with new cardiac decompensation at entry (p < 0.01), age (p < 0.01), no acute surgery (p < 0.05) and mitral valve involvement (p < 0.05). Multivariate analysis showed new cardiac decompensation at entry to be an independent predictor of cardiac death at 5 years follow-up (relative risk 2.39; CI 1.05-5.45), while no surgery during active disease implied a relative risk of 3.45, though not statistically significant. Patients undergoing surgery very early (< or = 10 days of treatment) did not have a poorer outcome. Acute valve replacement, as compared with medical therapy only, might be important to increase both short-term and long-term survival in infective endocarditis.