Association Between Surgical Indications, Operative Risk, and Clinical Outcome in Infective Endocarditis: A Prospective Study From the International Collaboration on Endocarditis
2015
Background-Use of surgery for the treatment of infective
endocarditis (IE) as related to surgical indications and
operative risk for mortality has not been well defined. Methods
and Results-The International Collaboration on
Endocarditis-PLUS (ICE-PLUS) is a prospective cohort of
consecutively enrolled patients with definite IE from 29
centers in 16 countries. We included patients from ICE-PLUS
with definite left-sided, non-cardiac device-related IE who
were enrolled between September 1, 2008, and December 31, 2012.
A total of 1296 patients with left-sided IE were included.
Surgical treatment was performed in 57% of the overall cohort
and in 76% of patients with a surgical indication. Reasons for
nonsurgical treatment included poor prognosis (33.7%),
hemodynamic instability (19.8%), death before surgery (23.3%),
stroke (22.7%), and sepsis (21%). Among patients with a
surgical indication, surgical treatment was independently
associated with the presence of severe aortic regurgitation,
abscess, embolization before surgical treatment, and transfer
from an outside hospital. Variables associated with nonsurgical
treatment were a history of moderate/severe liver disease,
stroke before surgical decision, and Staphyloccus aureus
etiology. The integration of surgical indication, Society of
Thoracic Surgeons IE score, and use of surgery was associated
with 6-month survival in IE. Conclusions-Surgical decision
making in IE is largely consistent with established guidelines,
although nearly one quarter of patients with surgical
indications do not undergo surgery. Operative risk assessment
by Society of Thoracic Surgeons IE score provides prognostic
information for survival beyond the operative period. S aureus
IE was significantly associated with nonsurgical management.
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