Early surgery best for infective endocarditis

By Sarah Guy

Compared with conventional treatment, early surgery for patients with infective endocarditis and large vegetations significantly reduces the risk for death or embolic events by reducing the risk for systemic embolism, show results from a randomized trial.

Specifically, the risk for death or embolic events within 6 weeks of being randomly assigned to either treatment strategy was 90% lower in the early surgery group than the conventional treatment group, report the researchers.

Indeed, no patients in the early surgery group - they were operated on within 48 hours of being randomly assigned to this treatment group - experienced embolic events, while eight in the conventional treatment group did, which is a statistically significant difference.

"We suggest that early surgery is a valuable therapeutic option to prevent embolism," say Duk-Hyun Kang (University of Ulsan, Seoul, South Korea) and colleagues in The New England Journal of Medicine.

Over a 5-year period, Kang and team assigned 76 patients with infective endocarditis and a median vegetation diameter of 12 mm to early surgery (n=37) or conventional treatment (n=39), where the latter observed 2006 American Heart Association recommendations that surgery is performed only if complications develop during medical treatment or if symptoms persist after antibiotic therapy.

Among conventionally treated patients, 27 underwent surgery during initial hospitalization, and three underwent surgery during the whole-cohort median follow up of 749 days.

One patient (3%) in the early surgery group versus nine (23%) in the conventional treatment group experienced the primary endpoint of death or embolic events within 6 weeks, giving a hazard ratio (HR) of 0.10, report the researchers.

At 6 weeks, rates of embolism were significantly higher in the conventional treatment than the early surgery group, at 21% versus 0%.

"Systemic embolism... is the second most common cause of death, after congestive heart failure, in this patient population," writes the research team.

In the longer-term follow up, no early surgery-treated patients experienced infective endocarditis recurrence, whereas one patient in the conventional treatment group did. There was no significant difference between treatment groups in all-cause mortality rates by 6 months, at 3% and 5% for early surgery and conventional treatment, respectively.

By contrast, the composite rate at 6 months of death from any cause, embolic events, recurrence of infective endocarditis, or repeat hospitalization due to the development of heart failure was significantly lower in the early surgery group (3%) than the conventional treatment group (28%), at a HR of 0.08.

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