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Emergency valve surgery improves clinical results in patients with infective endocarditis complicated with acute
Takaaki Samura1, Daisuke Yoshioka1, Koichi Toda1
1Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan.
Insights
Early valve surgery within 3 days for infective endocarditis (IE) patients with acute cerebral infarction (CI) improves survival and clinical outcomes without increasing neurological complications.
Area of Science:
- Cardiology
- Neurosurgery
- Infectious Diseases
Background:
- Optimal timing for valve surgery in infective endocarditis (IE) patients with acute cerebral infarction (CI) remains unclear.
- Previous studies had limitations due to unmatched cohorts.
- Propensity score matching can address confounding factors in comparative studies.
Purpose of the Study:
- To assess the feasibility and safety of early valve surgery (within 3 days) after CI in IE patients.
- To compare clinical outcomes between early and delayed valve surgery using propensity score matching.
Main Methods:
- A cohort of 152 IE patients with preoperative CI was analyzed from 2009-2017.
- 67 patients underwent early surgery (within 3 days), 85 underwent delayed surgery.
- 45 matched pairs were analyzed using propensity score matching to compare in-hospital death and neurological complications.
Main Results:
- Hospital mortality was significantly lower in the early surgery group (2% vs. 16%, P=0.058).
- Postoperative intracranial hemorrhage and neurological deterioration rates were similar between groups.
- Long-term survival rates were significantly higher in the early surgery group (P=0.029).
Conclusions:
- Early valve surgery within 3 days of CI in IE patients with small infarcts (<2 cm) improves clinical results.
- This strategy does not increase the incidence of postoperative neurological complications.
- Early intervention is a safe and effective approach for selected IE patients with CI.
Objectives:
To date, the optimal timing for patients with infective endocarditis (IE) with acute cerebral infarction (CI) to undergo valve surgery is unknown. Although some previous studies have reported that early valve surgery for IE patients within 1 or 2 weeks after CI could be performed safely, an initial strategy has not been identified because of the unmatched cohorts in previous studies. This study aimed to assess the feasibility and safety of early surgery within a few days after cerebral infarction by using propensity score matching.
Methods:
Between 2009 and 2017, 585 patients underwent valve surgery for patients with active IE at 14 institutions. Among these, 152 had preoperative acute CI. Early surgery was defined as surgery within 3 days after the diagnosis of CI. Of these 152 patients, 67 underwent early valve surgery (early group), whereas 85 underwent delayed valve surgery (delayed group). Of the patients, 45 in each group were analysed using propensity score matching. The primary outcome was in-hospital death after valve surgery, and secondary outcomes included neurological complications. We compared the clinical results of these matched patients.
Results:
Hospital mortality was lower in the early group (2% vs 16%, P = 0.058). The rate of postoperative intracranial haemorrhage in the early and delayed groups was 4% in both groups. The postoperative modified Rankin scale was not significantly different [early group: 0 (0-2); delayed group: 0 (0-2)]. Incidence of neurological deterioration did not differ significantly between the groups. The survival rates after the first discharge at 1, 3 and 5 years after valve operation were 100%, 97% and 97% in the early group and 91%, 83% and 80% in the delayed group, respectively (P = 0.029).
Conclusions:
Early valve surgery for patients with IE within 3 days after a CI measuring <2 cm in size improved clinical results without increasing the incidence of postoperative neurological complications.
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