Elsevier

American Heart Journal

Volume 210, April 2019, Pages 108-116
American Heart Journal

Clinical Investigation
Association between the timing of surgery for complicated, left-sided infective endocarditis and survival

https://doi.org/10.1016/j.ahj.2019.01.004Get rights and content

Background

In patients with active infective endocarditis (IE), the relationship between timing of surgery and survival is uncertain. The objective was to evaluate clinical characteristics associated with timing of surgery and the association between surgical timing and 6-month survival in complicated, left-sided IE.

Methods

In a prospective, multicenter, observational registry (The International Collaboration on Endocarditis-PLUS, registry from 2008 to 2012), clinical factors associated with timing of surgery during the index hospitalization were determined among 485 adult patients with definite, complicated, left-sided IE who underwent cardiac surgery during their index hospitalization. The relationship between early surgical intervention (<7 days from admission to surgery center) and outcome after surgery was analyzed. The primary end point of the study was 6-month survival.

Results

The median time to surgery from admission to surgical center was 7 (interquartile range 2-15) days. Patients who underwent earlier surgery were more likely transferred to the surgical center (74.2% vs 46.4%, P < .001) and had a lower percentage of preexisting heart failure (before IE diagnosis) (6.0% vs 17.3%, P < .001) but higher rate of acute heart failure (53.2% vs 38.4%, P = .001). Variables independently associated with surgery <7 days from admission were patient transfer, acute heart failure, and nonelective surgical status (C-index = 0.84), but predicted operative risk was not. Cox proportional hazards modeling with inverse probability of treatment weighting found that earlier surgery was associated with a trend toward higher 6-month mortality compared with later surgery (hazard ratio = 1.68, 95% CI 0.97-2.96; P = .065), particularly surgery within 2 days of admission or transfer. Mortality was significantly associated with operative risk and complicated IE, including Staphylococcus aureus infection and presence of abscess.

Conclusions

Earlier surgery in IE is strongly associated with acute heart failure and surgical urgency. After adjustment for operative risk and IE complications, earlier surgery <7 days from admission was associated with a trend toward higher 6-month overall mortality compared with surgery later in the index hospitalization.

Section snippets

Methods

The study population for this analysis was the International Collaboration on Endocarditis (ICE)-PLUS cohort, a prospective, multinational registry of consecutive cases of definite IE by modified Duke criteria,10 with prespecified definitions of variables, as previously described.6., 11. The ICE-PLUS registry includes 2,124 IE patients from 34 centers in 18 countries hospitalized between September 1, 2008, and December 31, 2012, with 6-month vital status follow-up data (all ICE sites listed in

Definitions

Definitions of the standard variables used in the ICE-PLUS database have been reported previously.4., 6., 11. The index hospitalization was defined as time between date of admission or transfer to ICE hospital to the date of discharge. Surgery during this hospitalization was defined by investigators at participating hospital as elective: the patient's cardiac function has been stable in the days or weeks prior to the operation, and the procedure could be deferred without increased risk of

Descriptive statistics

Baseline characteristics and clinical events of the quartiles of surgical timing are presented as medians with 25% and 75% percentile for continuous variables and frequencies with proportions for categorical variables. Statistical comparisons between groups were made with Wilcoxon rank-sum test for continuous variables and Fisher exact test for categorical variables.

Propensity score model

A multivariable logistic regression model was fit to calculate a propensity score (probability) for early surgical treatment. The response variable was receipt of cardiac surgery for IE during the index hospitalization at time less than median time to surgery. The model included variables that were selected a priori by an experienced cardiologist (A. W.) and from practice guidelines2., 3. and previous studies4., 13., 14. as those that would be evaluated in the decision to treat IE with surgery.

Survival analysis

A Cox proportional hazards model to predict survival at 6 months after discharge was fit in the ICE-PLUS data set, including variables associated with survival at P < .15 in univariable analysis. Two models were fit. In the first, surgery was included as an indicator variable for surgery performed <7 days after admission, with weighting by the inverse probability (propensity) of early surgery. To explore the timing of surgery in more depth, a second model (without inverse probability weighting)

Results

The median time to surgery was 7 days (interquartile range [IQR] 2-15), and the time to surgery relative to admission to ICE surgical center is shown in Figure 2. The clinical, microbiologic, and echocardiographic characteristics of the patients who met study inclusion criteria and underwent surgery during index hospitalization for IE (n = 485) in the ICE-PLUS registry are shown in Table I by quartile of surgical timing (quartile 1 = 0-1 day, quartile 2 = 2-6 days, quartile 3 = 7-15 days,

Discussion

A high percentage of patients with left-sided IE develop indications for surgical intervention, generally soon after IE diagnosis,4 but the relationship between surgical timing and outcome is not well defined. In this prospective, multinational cohort of IE, we found that earlier surgery <7 days from admission is strongly predicted by acute heart failure, referral, and surgical urgency but not other surgical indications. A high percentage of patients with surgical indications undergo surgery

Disclosures

Jose M. Miro, MD, PhD, received consulting honoraria and/or research grants from AbbVie, Angelini, Bristol-Myers Squibb, Jansen, Genentech, Medtronic, Merck, Novartis, Gilead Sciences, and ViiV Healthcare.

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  • Cited by (0)

    Funding: Jose M. Miro, MD, PhD, received a research grant from the Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain, during 2017-19.

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