Timing of surgery for endocarditis

Bacterial endocarditis continues to carry a substantial risk of death.  Whilst surgical intervention in patients with incipient heart failure is recognised as efficacious, the timing and indications for surgical intervention to prevent systemic embolism remain controversial.  In this small, single centre study Kang et al compared the clinical outcome of early surgery versus conventional treatment with antibiotics and prospective future intervention.  Recruiting a total of 76 patients with left-sided infective endocarditis, severe valve disease, and large vegetations (>10mm), patients were randomised in a 1:1 fashion either to early surgery (37) or conventional treatment (39) with the primary end point being  a composite of in-hospital death and embolic events occurring within 6 weeks of randomization.  Patients in the early-surgery group underwent valve surgery within 48 hours of randomization, whereas 30 patients (77%) in the conventional-treatment group underwent surgery during the initial hospitalization (27 patients) or during follow-up.  The results highly favoured early surgical intervention with the primary end point occurring in 1 patient (3%) in the early-surgery group compared with 9 (23%) in the conventional-treatment group (HR, 0.10; 95% CI, 0.01 to 0.82; P=0.03).  This was driven primarily by a reduction in embolic events with the composite end point of death from any cause, embolic events, or recurrence of infective endocarditis at 6 months being 3% in the early-surgery group and 28% in the conventional-treatment group (HR, 0.08; 95% CI, 0.01 to 0.65; P=0.02) but with no difference in all-cause mortality at 6 months(3% and 5%, respectively; HR, 0.51; 95% CI, 0.05 to 5.66; P=0.59).

Conclusions

As compared with conventional treatment, early surgery in patients with infective endocarditis and large vegetations significantly reduced the composite end point of death from any cause and embolic events by effectively decreasing the risk of systemic embolism.

  •  Kang DH, Kim YJ, Kim SH, Sun BJ, Kim DH, Yun SC, Song JM, Choo SJ, Chung CH, Song JK, Lee JW, Sohn DW.  Early surgery versus conventional treatment for infective endocarditis. N Engl J Med. 2012 Jun 28;366(26):2466-73.