Valve surgery in active infective endocarditis: A simple score to predict in-hospital prognosis

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Abstract

Aims

Surgery for infective endocarditis (IE) is associated with high mortality. Our objectives were to describe the experience with surgical treatment for IE in Spain, and to identify predictors of in-hospital mortality.

Methods

Prospective cohort of 1000 consecutive patients with IE. Data were collected in 26 Spanish hospitals.

Results

Surgery was performed in 437 patients (43.7%). Patients treated with surgery were younger and predominantly male. They presented fewer comorbid conditions and more often had negative blood cultures and heart failure. In-hospital mortality after surgery was lower than in the medical therapy group (24.3 vs 30.7%, p = 0.02). In patients treated with surgery, endocarditis involved a native valve in 267 patients (61.1%), a prosthetic valve in 122 (27.9%), and a pacemaker lead with no clear further valve involvement in 48 (11.0%). The most common aetiologies were Staphylococcus (186, 42.6%), Streptococcus (97, 22.2%), and Enterococcus (49, 11.2%). The main indications for surgery were heart failure and severe valve regurgitation. A risk score for in-hospital mortality was developed using 7 prognostic variables with a similar predictive value (OR between 1.7 and 2.3): PALSUSE: prosthetic valve, age  70, large intracardiac destruction, Staphylococcus spp, urgent surgery, sex [female], EuroSCORE  10. In-hospital mortality ranged from 0% in patients with a PALSUSE score of 0 to 45.4% in patients with PALSUSE score > 3.

Conclusions

The prognosis of IE surgery is highly variable. The PALSUSE score could help to identify patients with higher in-hospital mortality.

Introduction

Infective endocarditis (IE) is a severe disease that is associated with high morbidity and mortality. Surgery is increasingly used to treat IE [1], [2], to the extent that is now considered necessary in about half of all cases of left-sided IE [3]. The main indications for surgery are substantial intracardiac destruction, low likelihood of cure with medical therapy alone, persistent bacteraemia or fever, new heart block, large vegetations, high risk of embolism, and heart failure due to valvular dysfunction.

However, surgery for active IE is associated with a high mortality rate and recent advances in surgical procedure and perioperative management do not seem to have changed the outcome of surgical significantly. In-hospital mortality rates vary from 6% to 36% [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18]. Moreover, even in the same centre, surgical prognosis of IE is heterogeneous as it depends on microbiologic aetiology, baseline conditions and mode of presentation.

The scoring systems used for prognostic classification in cardiac surgery include the European System for Cardiac Operative Risk Evaluation (EuroSCORE) and the Society of Thoracic Surgeons (STS) scores. However, neither is specific for endocarditis, in which surgery has higher postoperative morbidity and mortality than most other heart procedures. In fact, the need for a specific risk score system to aid decision-making in IE surgery has been highlighted [14].

Our objectives were to describe the experience with surgical treatment of active IE in Spain and to identify predictive factors for operative mortality.

Section snippets

Methods

Consecutive patients with IE were prospectively included in the registry “Spanish Collaboration on Endocarditis — Grupo de Apoyo al Manejo de la Endocarditis infecciosa en ESpaña (GAMES)” between January 1, 2008 and December 31, 2010 in 26 Spanish hospitals. Multidisciplinary teams completed a standardized case report form. Regional and local ethics committees approved the study, and patients gave their informed consent.

Results

A total of 1000 patients presented definite IE (852) or possible IE (148). Surgery was performed in 437 patients (43.7%). It was initially indicated in 630 (63.0%) but 193 patients were considered inoperable or died before surgery. Patients treated with surgery presented different clinical characteristics from those who received only medical therapy (Table 1). Of note surgical patients were younger and less frequently female and presented less comorbidity. However they presented blood culture

Discussion

Our main findings are as follows: 1) patients with IE commonly undergo surgery (44%); 2) the main indication for surgery is heart failure; 3) patients treated with surgery have a better clinical profile, as they are younger and present fewer comorbid conditions. This could contribute to the lower in-hospital mortality in operated patients; and 4) in-hospital mortality after IE surgery was still high (24%). The PALSUSE score is easy to calculate and is associated with in-hospital mortality,

Conclusion

Surgery for active IE is associated with an elevated mortality rate that varies largely according to patient characteristics. In the present study we established independent IE-specific predictors of mortality (prosthetic valve, substantial intracardiac destruction, Staphylococcus species), and generic predictors of mortality (age, female sex, urgent surgery and EuroSCORE). The PALSUSE score could help to identify patients with higher in-hospital mortality following IE surgery.

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  • Cited by (0)

    Funding. This work was supported in part by the RIC (Red de Investigación Cardiovascular): RD 12/ 0042/0001.

    1

    All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

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