Clinical question: Is early surgery associated with better survival in patients with prosthetic valve endocarditis (PVE)?
Background: PVE occurs in 3% to 6% of patients within five years of valve implantation. Consensus guidelines, based on expert opinion, recommend surgical intervention with debridement and valve replacement in PVE, especially for patients with complications that are unlikely to be successfully treated with medical therapy, such as valve dysfunction, heart failure, and cardiac abscesses. Studies comparing survival with medical therapy versus surgery have reported conflicting results.
Study Design: Multi-center, prospective, cohort study.
Setting: International, multi-center cohort of patients from tertiary care hospitals.
Synopsis: The International Collaboration on Endocarditis—Prospective Cohort Study (ICE-PCS) cohort consisted of 1025 patients with PVE, 490 of whom underwent early surgery and 535 of whom received medical therapy alone.
Unadjusted initial analysis showed early surgery was associated with lower mortality; however, this survival benefit was not evident after the data was adjusted for treatment selection bias and survivor bias for in-hospital mortality and one-year mortality. The hazard ratios were 0.9 (95% CI 0.76 -1.07) and 1.04 (95% CI 0.89 -1.23), respectively.
Subgroup analysis indicated that early surgery in patients with high-risk features was associated with fewer poor outcomes compared to medical therapy: 28% versus 50% (P=.007)
Bottom line: Early surgery may not be associated with mortality benefits for PVE. High-risk patients, however, still might benefit from early surgery.
Citation: Lalani T, Chu VH, Park LP, et al. In-hospital and 1-year mortality in patients undergoing early surgery for prosthetic valve endocarditis. JAMA Intern Med. 2013:173:1495-1504.