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