The association between vegetation size and surgical treatment on 6-month mortality in left-sided infective endocarditis

Author:

Fosbøl Emil L12,Park Lawrence P1,Chu Vivian H1,Athan Eugene3,Delahaye Francois4,Freiberger Tomas56,Lamas Cristiane7,Miro Jose M8,Strahilevitz Jacob9,Tribouilloy Christophe1011,Durante-Mangoni Emanuele12,Pericas Juan M8,Fernández-Hidalgo Nuria13,Nacinovich Francisco14,Rizk Hussein15,Barsic Bruno16,Giannitsioti Efthymia17,Hurley John P18,Hannan Margaret M18,Wang Andrew1,

Affiliation:

1. Duke University Medical Center, Durham, NC, USA

2. Department of Cardiology, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark

3. Barwon Health and Deakin University, Geelong, Australia

4. Hospital Louis Pradel, Lyon-Bron, France

5. Centre for Cardiovascular Surgery and Transplantation, Brno, Czech Republic

6. Central European Institute of Technology, Masaryk University, Brno, Czech Republic

7. Instituto Nacional de Cardiologia and Unigranrio, Rio de Janeiro, Brazil

8. Infectious Diseases Service, Hospital Clinic—IDIBAPS, University of Barcelona, Barcelona, Spain

9. Hadassah-Hebrew University Medical Center, Jerusalem, Israel

10. University Hospital, Amiens, France

11. INSERM U-1088, University of Picardie, Amiens, France

12. Internal Medicine, University of Campania, Monaldi Hospital, Naples, Italy

13. Servei de MalaltiesInfeccioses, Hospital Universitari de Barcelona, Barcelona, Spain

14. Instituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina

15. Cairo University Hospital, Cairo, Egypt

16. School of Medicine University of Zagreb, Hospital for Infectious Diseases, Zagreb, Croatia

17. Attikon University General Hospital, Athens, Greece

18. Mater Misericordiae University Hospital, Dublin, Ireland

Abstract

Abstract Aims In left-sided infective endocarditis (IE), a large vegetation >10 mm is associated with higher mortality, yet it is unknown whether surgery during the acute phase opposed to medical therapy is associated with improved survival. We assessed the association between surgery and 6-month mortality as related to vegetation size. Methods and results Patients with definite, left-sided IE (2008–2012) from The International Collaboration on Endocarditis prospective, multinational registry were included. We compared clinical characteristics and 6-month mortality (by Cox regression with inverse propensity of treatment weighting) between patients with vegetation size ≤10 mm vs. >10 mm in maximum length by surgical treatment strategy. A total of 1006 patients with left sided IE were included; 422 with a vegetation size ≤10 mm (median age 66.0 years, 33% women) and 584 (median age 58.4 years, 34% women) patients with a large vegetation >10 mm. Operative risk by STS-IE score was similar between groups. Embolic events occurred in 28.4% vs. 44.3% (P < 0.001), respectively. Patients with a vegetation >10 mm was associated with higher 6-month mortality (25.1% vs. 19.4% for small vegetation, P = 0.035). However, after propensity adjustment, the association with higher mortality persisted only in patients with a large vegetation >10 mm vs. ≤10 mm: hazard ratio (HR) 1.55 (1.27–1.90); but only in patients with large vegetation managed medically [HR 1.86 (1.48–2.34)] rather than surgically [HR 1.01 (0.69–1.49)]. Conclusion Left-sided IE with vegetation size >10 mm was associated with an increased mortality at 6 months in this observational study but was dependent on treatment strategy. For patients with large vegetation undergoing surgical treatment, survival was similar to patients with smaller vegetation size.

Funder

FAPERJ

Institut d'Investigacions Biomèdiques August Pi i Sunyer

IDIBAPS

Publisher

Oxford University Press (OUP)

Subject

Cardiology and Cardiovascular Medicine

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