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.

Attikon University General Hospital Athens Greece

Barwon Health and Deakin University Geelong Australia

Centre for Cardiovascular Surgery and Transplantation Brno and Central European Institute of Technology Masaryk University Brno Czech Republic

Duke University Medical Center Durham NC

Hadassah Hebrew University Medical Center Jerusalem Israel

Hospital Louis Pradel Lyon Bron France

Infectious Diseases Service Hospital Clinic IDIBAPS University of Barcelona Barcelona Spain

Instituto Cardiovascular de Buenos Aires Buenos Aires Argentina

Instituto Nacional de Cardiologia and Unigranrio Rio de Janeiro Brazil

Internal Medicine University of Campania Monaldi Hospital Naples Italy

Mater Misericordiae University Hospital Dublin Ireland

School of Medicine University of Zagreb Hospital for Infectious Diseases Zagreb Croatia

Servei de Malalties Infeccioses Hospital Universitari Vall d'Hebron Universitat Autònoma de Barcelona Barcelona Spain

University Hospital Amiens France and INSERM U 1088 University of Picardie Amiens France

Am Heart J. 2019 Jun;212:165. doi: 10.1016/j.ahj.2019.03.006. PubMed

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