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Bernard D. Prendergast and Pilar TornosSurgery for Infective Endocarditis: Who and When?

Print ISSN: 0009-7322. Online ISSN: 1524-4539 Copyright © 2010 American Heart Association, Inc. All rights reserved

.is published by the American Heart Association, 7272 Greenville Avenue,

Dallas, TX 75231Circulation

doi: 10.1161/CIRCULATIONAHA.108.7735982010;121:1141-1152Circulation. World Wide Web at: The online version of this article, along with updated information and s ervices, is located on the

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Surgery forInfective Endocarditis

Who andWhen?

Bernard D.Prendergast, DM,FRCP; PilarTornos, MD,FESC I nfective endocarditis(IE) remainsa dangerouscondition with unchangingincidence anda mortalityapproaching

30% at1 year.

1,2

Surgery ispotentially lifesaving

3 and is required in25% to50% ofcases duringacute infectionand

20% to40% duringconvalescence.

4-7

Operative procedures

are oftentechnically difficultand associatedwith highrisk, not leastbecause patientsare frequentlyextremely sickwith multisystem disease.Nevertheless, indicationsfor surgeryare clear inmany patients,and internationalguidelines 8,9 provide strong recommendationsthat areapplicable forthe majority. These guidelinesare notsupported byrobust clinicalevi- dence, however,and clinicaldecision makingis oftenham- pered bydiverse considerations,including advancingage of the overallpatient cohort,the presenceof extracardiaccom- plications orpreexistent comorbidity,prior antibiotictherapy of varyingduration, andthe availabilityof appropriate surgical expertise.In thisarticle, wereview theevidence base that supportscurrent clinicalpractice andattempt toprovide recommendations inareas wheredoubt persists.

The Roleof Surgery

The roleof surgeryin activeIE hasexpanded progressively since earlyreports ofsuccessful outcome. 10

Subsequent

declines inmortality maybe attributedto avariety of improvements inmanagement, althoughexpeditious surgery in carefullyselected patientshas playeda majorrole. Con- temporary datain Europeindicate thatsurgery isnow undertaken inapproximately 50%of patientswith IE;the most frequentindications arecongestive heartfailure (60%), refractory sepsis(40%), emboliccomplications (18%),and vegetation size(48%), witha combinationof thesefactors being presentin manypatients. 11 Overall surgicalmortality inactive IEis 6%to 25%,with long-term survivalrates ofapproximately 70%in most series.

4-7,12-31

Assessment ofthe impactof surgeryon out-

come isdifficult, becausethe patientsreferred arefrequently those withsevere complicationsrelated tovirulent organisms. Conversely, themost illpatients (frequentlythe elderly,with attendant comorbidity)are oftendeemed unfitfor surgery.In

general terms,prognosis isbetter ifsurgery isundertaken early, beforecardiac tissuedestruction anddeterioration in

the overallcondition ofthe patientincrease thehazards of intervention. Finaloutcome hasnever beenrelated tothe duration andintensity ofprior antibiotictreatment, and surgery shouldnot bedelayed whenclearly indicatedin the vain hopethat asterile operativefield canbe achieved.

Numerous serieshave attemptedto identifyvariables

predictive ofearly andlate mortality,

4-6,12-25

and theseare summarized inTable 1.However, interpretationis hampered by theheterogeneous natureof thepatients studiedand the outcome measuresused. Specifically,the vastmajority of studies havebeen single-center,retrospective seriesenrolling patients withboth nativeand prostheticvalve IE.Further- more, analysisis inherentlybiased giventhe selectionof patients forsurgery whohave ananticipated pooroutcome but acceptableoperative risk.Although surgerymay be recommended andcommonly performedfor indicationssuch as emboliccomplications orpersistent infection,it shouldbe recognized thatno definitiveproof existsof improvedout- come inthese situations(in contrastto congestiveheart failure dueto valvularregurgitation; seebelow). Morerecent investigations usingsophisticated propensityscoring models have yieldedconflicting resultson thebenefits ofsur- gery,

15,22-25

and afuture needexists forhigh-quality prospec- tive assessment.Even withthe helpof thesedata, decision making isfrequently difficult,and overallmanagement is highly dependenton theexperience ofthe surgicalteam (as well asthe individualsurgeon) anda stronginteraction with cardiology andmicrobiology colleagues.

Surgical Management

Preoperative Considerations

Transthoracic andtransesophageal echocardiographyare now ubiquitous, andtheir utilityin theassessment ofcomplica- tions ofIE isclearly recognized.Transesophageal imaging has superiorsensitivity andspecificity andis recommended in virtuallyall patientsin whomsurgery iscontemplated. Cardiac catheterizationis unnecessaryfor diagnosisand anatomic characterization.Coronary angiographyshould be

From theDepartments ofCardiology (B.D.P.),The JohnRadcliffe Hospital,Oxford, UnitedKingdom andHopital VallD'Hebron (P.T.),Barcelona,

Spain.

Correspondence toDr B.D.Prendergast, ConsultantCardiologist, TheJohn RadcliffeHospital, HeadleyWay, Headington,Oxford, OX39DU, United

Kingdom. E-mailbernard.prendergast@orh.nhs.uk

Circulation

.2010;121:1141-1152.)

© 2010American HeartAssociation, Inc.

Circulationis availableat http://circ.ahajournals.orgDOI: 10.1161/CIRCULATIONAHA.108.773598 1141
Valvular HeartDisease: ChangingConcepts inDisease Management by guest on August 29, 2013http://circ.ahajournals.org/Downloaded from Table 1.Key ArticlesAssessing SurgicalOutcome inIE

First Author

and

Reference

Citation YearStudy DesignStatistical

Methods SettingNo. of

SubjectsPatient

CharacteristicsIn-Hospital

Mortality,

%Mean

Follow-Up,

yLong- Term

Survival

Rate, %Summary ofFindings

Jault 4

1997 Retrospective

single-center surgical cohort studyMultivariate logistic regression analysisFrance 247Native valveIE alone; surgery

100%7.6

(Surgical series)6 71Predictors ofoperative mortality: age, insidiousillness, CHF.

Long-term survivalgood except

for neurologicalcomplications and mitralvalve IE.

Castillo

5

2000 Prospective

single-center cohort studySimple group comparisonsSpain 138Native valveIE

69%, PVE

31%; surgery

51%Overall 21;

surgical 21,
medical 20 P

NS)10 71Early surgeryassociated with

good long-termresults andno increase inmortality. Nota comparative study.

Alexiou

12

2000 Retrospective

single-center surgical cohort studyMultivariate logistic regression analysisUK 118Native valveIE

70%, PVE

30%; surgery

100%7.6

(Surgical series)10 73Predictors ofoperative mortality:

CHF, impairedLV function.

Predictors ofrecurrence: PVE.

Predictors oflate mortality:

myocardial invasion, reoperation. Predictorsof poor long-term survival: coagulase-negative staphylococcus, annular abscess, longICU stay.

Wallace

13

2002 Retrospective

single-center cohort studyMultivariate logistic regression analysisUK 208Native valveIE

68%, PVE

32%; surgery

52%Overall 18;

impact of surgery not reported0.5 73Duration ofillness, age,gender, site ofinfection, organism,and

LV functiondid notpredict

outcome. Abnormalwhite cell count, raisedcreatinine, 2

Duke criteria,or visible

vegetation conferredpoor prognosis.

Hasbun

14

2003 Retrospective

multicenter cohort studyMultivariate logistic regression analysisUSA 513Native valveIE alone; surgery

45%Not

reported0.5 74Mortality associatedwith comorbidity, abnormalmental status, CHF,nonstreptococcal

IE, ormedical therapy.

Prognostic classification

proposed.

Vikram

15

2003 Retrospective

multicenter cohort studyPropensity analysisUSA 513Native valveIE alone; surgery

45%Not

reported0.5 74Valve surgeryassociated with reduced mortalityafter adjustment forbaseline variables andpropensity scores.

Benefits ofsurgery greatestin

patients withCHF. Habib 16

2005 Retrospective

multicenter cohort studyMultivariate logistic regression analysisFrance 104PVE alone; surgery 49%Overall 21; surgical 17, medical 25 P

NS)2.7 62Predictors ofin-hospital

mortality: CHF,S aureus.

Predictors oflong-term

mortality: earlyPVE, comorbidity, CHF, staphylococcal infection,new prosthetic dehiscence.Mortality reduced bysurgery inhigh-risk subgroups withstaphylococcal infection andcomplicated PVE.

Delahaye

17

2007 Prospective

multicenter population- based surveyMultivariate logistic regression analysisFrance 559Native valveIE

85%, PVE

15%; surgery

47%Overall 17;

surgical 14, medical 19 P

NS)Not

reportedNot reportedPredictors ofmortality: CHF, immunosuppression, insulin dependent DM,left-sided IE, septic shock,coma, cerebral hemorrhage, highC-reactive protein.

Continued

1142 CirculationMarch 9,2010

by guest on August 29, 2013http://circ.ahajournals.org/Downloaded from

Table 1.Continued

First Author

and

Reference

Citation YearStudy DesignStatistical

Methods SettingNo. of

SubjectsPatient

CharacteristicsIn-Hospital

Mortality,

%Mean

Follow-Up,

yLong- Term

Survival

Rate, %Summary ofFindings

San

Román

18

2007 Prospective

multicenter cohort studyMultivariate logistic regression analysisSpain 317Native valveIE

64%, PVE

36%; surgery

28%Overall 21Not

reportedNot reportedPredictors ofhigh risk: interhospital transfer,AV block, acute onset,CHF, periannular complications,S aureus infection.

Revilla

19

2007 Prospective

multicenter cohort studyMultivariate logistic regression analysisSpain 508Native valveIE

66%, PVE

34%; surgery

100%Overall 36;

native valve 32,

PVE 45

(surgical series)Not reportedNot reportedPoor clinicaloutcome after urgent surgery.Persistent infection andrenal failure associated withhigher mortality. Hill 20

2007 Prospective

single-center cohort studyMultivariate logistic regression analysisBelgium 193Native valveIE

66%, PVE

34%; surgery

63%Not

reported0.5 78

Overall

(26 ifCI to surgery)Predictors ofmortality: age,S aureus , CIto surgery(present in

50% ofdeaths).

Remadi

21

2007 Prospective

multicenter cohort studyMultivariate logistic regression analysisFrance 116S aureusIE alone; native valve IE83%,

PVE 17%;

surgery 47%Overall 26; surgical 16, medical 34 P

0.05)3 57Predictors ofmortality:

comorbidity, CHF,severe sepsis,

PVE, majorneurological events.

Early surgeryassociated with

improved outcome. Wang 6

2007 Prospective

multicenter cohort studyMultivariate logistic regression analysisGlobal registry556 PVEalone; surgery 49%Overall 23; impact of surgery not reportedNot reportedNot reportedPredictors ofin-hospital mortality: age, healthcare-associated infection,

S aureusinfection, CHF,stroke,

intracardiac abscess,persistent bacteremia. Aksoy 22

2007 Prospective

single-center cohort studyPropensity score matching: logistic regression analysisUSA 426Native valveIE

69%, PVE

19%, "other"

12%; surgery

29%Overall 17;

left-sided

IE: surgical

12, medical 185 Surgical 48,
medical

28Factors associatedwith surgical

treatment: age,interhospital transfer, staphylococcal infection, CHF,intracardiac abscess, hemodialysiswith IV catheter. Surgeryassociated with long-termbenefit. Factors associated withmortality: DM, paravalvular infection,indwelling

IV catheter.

Tleyjeh

23

2007 Retrospective

single-center cohort studyMatched propensity analysisUSA 546Native valveIE alone; surgery

24%Not

reported0.5 Surgical 73,
medical

76No survivalbenefits associated

with surgerydespite correction for timingand earlyoperative deaths. Prospectivestudy recommended.

Tleyjeh

24

2008 Retrospective

single-center cohort studyPropensity analysisUSA 546Native valveIE alone; surgery

24%Not

reported0.5 Surgical 73,
medical

76Strong correlationbetween

propensity scoreand timingof surgery. Individualeffect of each variabledifficult to measure. Thuny 25

2009 Retrospective

single center observational cohort studyPropensity analysisFrance 291Native valveIE

82%, PVE

18%; surgery

100%Not

reported6 months13% Veryearly surgery( 7 days) associated withimproved survival (especiallyin highest risk patients)but greater likelihood ofrelapse or post-operative valvedysfunction.

CHF indicatescongestive heartfailure; PVE,prosthetic valveendocarditis; NS,not significant;UK, UnitedKingdom; LV,left ventricle;ICU, intensive careunit; USA,

United States;CI, contraindication;IV, intravenous;DM, diabetesmellitus; andAV, atrioventricular. Prendergast andTornos Surgeryfor InfectiveEndocarditis 1143 by guest on August 29, 2013http://circ.ahajournals.org/Downloaded fromquotesdbs_dbs46.pdfusesText_46

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