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Original Investigation |

In-Hospital and 1-Year Mortality in Patients Undergoing Early Surgery for Prosthetic Valve Endocarditis

Tahaniyat Lalani, MD, MHS1; Vivian H. Chu, MD, MHS2; Lawrence P. Park, PhD2; Enrico Cecchi, MD3; G. Ralph Corey, MD2; Emanuele Durante-Mangoni, MD4; Vance G. Fowler Jr, MD, MHS2; David Gordon, MBBS, PhD, FRCPA, FRACP, FFoSc5; Paolo Grossi, MD, PhD6; Margaret Hannan, MD7; Bruno Hoen, MD, PhD8; Patricia Muñoz, MD, PhD9; Hussien Rizk, MD10; Souha S. Kanj, MD11; Christine Selton-Suty, MD12; Daniel J. Sexton, MD13; Denis Spelman, MD14; Veronica Ravasio, MD15; Marie Françoise Tripodi, MD4; Andrew Wang, MD13 ; for the International Collaboration on Endocarditis–Prospective Cohort Study Investigators
[+] Author Affiliations
1Infectious Disease Clinical Research Program, Bethesda, Maryland
2Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
3Maria Vittoria Hospital, Torino, Italy
4II Università di Napoli, Naples, Italy
5Flinders Medical Centre, Bedford Park, South Australia, Australia
6Ospedale di Circolo Varese, Varese, Italy
7Mater Misericordiae University Hospital, Dublin, Ireland
8University Medical Center of Besançon, Besançon, France
9Hospital General Universitario Gregorio Marañón, Madrid, Spain
10Cairo University Medical School, Cairo, Egypt
11American University of Beirut Medical Center, Beirut, Lebanon
12CHU Nancy-Brabois, Nancy, France
13Department of Medicine, Duke University Medical Center, Durham, North Carolina
14Alfred Hospital, Melbourne, Victoria, Australia
15Ospedali Riuniti di Bergamo, Bergamo, Italy
JAMA Intern Med. 2013;173(16):1495-1504. doi:10.1001/jamainternmed.2013.8203.
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Importance  There are limited prospective, controlled data evaluating survival in patients receiving early surgery vs medical therapy for prosthetic valve endocarditis (PVE).

Objective  To determine the in-hospital and 1-year mortality in patients with PVE who undergo valve replacement during index hospitalization compared with patients who receive medical therapy alone, after controlling for survival and treatment selection bias.

Design, Setting, and Participants  Participants were enrolled between June 2000 and December 2006 in the International Collaboration on Endocarditis–Prospective Cohort Study (ICE-PCS), a prospective, multinational, observational cohort of patients with infective endocarditis. Patients hospitalized with definite right- or left-sided PVE were included in the analysis. We evaluated the effect of treatment assignment on mortality, after adjusting for biases using a Cox proportional hazards model that included inverse probability of treatment weighting and surgery as a time-dependent covariate. The cohort was stratified by probability (propensity) for surgery, and outcomes were compared between the treatment groups within each stratum.

Interventions  Valve replacement during index hospitalization (early surgery) vs medical therapy.

Main Outcomes and Measures  In-hospital and 1-year mortality.

Results  Of the 1025 patients with PVE, 490 patients (47.8%) underwent early surgery and 535 individuals (52.2%) received medical therapy alone. Compared with medical therapy, early surgery was associated with lower in-hospital mortality in the unadjusted analysis and after controlling for treatment selection bias (in-hospital mortality: hazard ratio [HR], 0.44 [95% CI, 0.38-0.52] and lower 1-year mortality: HR, 0.57 [95% CI, 0.49-0.67]). The lower mortality associated with surgery did not persist after adjustment for survivor bias (in-hospital mortality: HR, 0.90 [95% CI, 0.76-1.07] and 1-year mortality: HR, 1.04 [95% CI, 0.89-1.23]). Subgroup analysis indicated a lower in-hospital mortality with early surgery in the highest surgical propensity quintile (21.2% vs 37.5%; P = .03). At 1-year follow-up, the reduced mortality with surgery was observed in the fourth (24.8% vs 42.9%; P = .007) and fifth (27.9% vs 50.0%; P = .007) quintiles of surgical propensity.

Conclusions and Relevance  Prosthetic valve endocarditis remains associated with a high 1-year mortality rate. After adjustment for differences in clinical characteristics and survival bias, early valve replacement was not associated with lower mortality compared with medical therapy in the overall cohort. Further studies are needed to define the effect and timing of surgery in patients with PVE who have indications for surgery.

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Figure 1.
Kaplan-Meier Curves for the Cumulative Probability of Survival at 1 Year

Cox proportional hazards model weighted by the inverse probability of treatment.

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Figure 2.
Distribution of Key Predictors of Surgery Across the Propensity Quintiles in a Cohort of Patients With Prosthetic Valve Endocarditis

NYHA I-IV indicates New York Heart Association class I to IV heart failure. aTransesophageal or transthoracic echocardiographic evidence of paravalvular abscess or fistula formation. bTransesophageal or transthoracic echocardiographic evidence of dehiscence or severe regurgitation.

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Figure 3.
In-Hospital Mortality Rates for Patients With Prosthetic Valve Endocarditis by Propensity Quintile for Surgery

Data are given as mortality point estimates; error bars indicate 95% CIs.aFisher exact P value.

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Place holder to copy figure label and caption
Figure 4.
One-Year Mortality Rates for Patients With Prosthetic Valve Endocarditis by Propensity Quintile for Surgery

Data are given as mortality point estimates; error bars indicate 95% CIs.aFisher exact P value.

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