Prosthetic valve endocarditis (PVE) occurs in 3-6% of patients within 5 years of valve implantation and is associated with significant morbidity and mortality. Studies comparing outcomes following early surgical intervention as compared with medical therapy in PVE patients have been conflicting. The ICE-PCS is a multinational prospective cohort study of patients with infective endocarditis. A total of 1,025 patients hospitalized with definitive PVE between January 2000 and December 2006 were included in this analysis. In patients with PVE, 47.8% patients underwent surgery during the initial hospitalization and 52.2% received medical therapy alone. Overall in-hospital (24.5%) and 1-year (32.1%) mortality rates were high. After adjustment for treatment selection and survivor bias, early surgery was not associated with survival benefit (in-hospital mortality HR 0.90, 95% CI 0.76 – 1.07 and 1 yr mortality HR 1.04, 95% CI 0.89 – 1.23). Benefit with early surgery was seen in the subgroup of patients with clinical findings that meet current American Heart Association/American College of Cardiology guidelines for early surgery (i.e. valve regurgitation, vegetation, dehiscence and para-valvular abscess).
Surgical treatment is not associated with improved outcomes in all patients with PVE. However, surgery is associated with survival benefit among the subgroup of PVE patients with guideline recommended indications for surgical intervention. Future studies are needed to understand the optimal timing of surgery for PVE patients with guideline concordant indications for surgery.
- Lalani T, Chu VH, Park LP, et al. In-hospital and 1-year mortality in patients undergoing early surgery for prosthetic valve endocarditis. JAMA internal medicine. Sep 9 2013;173(16):1495-1504.