Impact of Adherence to Guideline-Recommended Surgical Timing on Outcomes in Infective Endocarditis

Background: Infective endocarditis (IE) frequently requires surgical intervention; however, the prognostic impact of adherence to guideline-recommended surgical timing remains uncertain. We aimed to evaluate the association between adherence to recommended surgical timing and short- and mid-term mortality in patients with IE undergoing surgery. Methods: We conducted a retrospective, observational single-center study including consecutive patients diagnosed with IE and an indication for surgery who underwent surgery during the index hospitalization between January 2000 and April 2021. Patients were classified according to whether surgery was performed within or outside the guideline-recommended time frame based on surgical priority. The primary endpoint was 30-day all-cause mortality. Secondary endpoints included in-hospital complications and one-year mortality. Multivariable logistic and Cox regression analyses were performed to evaluate the association between adherence to recommended surgical timing and outcomes. Results: Among 368 patients with IE, 282 (76.6%) had an indication for surgery; 193 surgically treated patients were included in the analysis. Surgery was performed within the recommended time frame in 148 patients (76.7%) and outside the recommended time frame in 45 (23.3%). Thirty-day mortality was 20.2%, with no significant differences between groups (19.6% vs. 22.2%; OR 0.85, 95% CI 0.38-1.92; p = 0.701). In multivariable analysis, no association was observed between adherence to guideline-recommended surgical timing and 30-day mortality (OR 1.97, 95% CI 0.77-5.04; p = 0.159) or one-year mortality (HR 1.19, 95% CI 0.65-2.17; p = 0.578). Society of Thoracic Surgeons (STS) score remained independently associated with both short- and mid-term mortality. Results were consistent in a sensitivity analysis including patients who died before surgery and in a propensity-score overlap weighting analysis. Conclusions: In this cohort of patients with IE and surgical indication who underwent surgery during the index hospitalization, adherence to guideline-recommended surgical timing was not associated with short- and mid-term mortality. Preoperative risk was independently associated with both short- and mid-term mortality, whereas surgical priority was associated with short-term mortality. Future prospective studies are needed to better characterize the role of surgical timing in the prognosis of IE.