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Despite the inclusion of surgical intervention in the management of infective endocarditis (IE) for decades, no clinical trial has been conducted to evaluate this treatment's efficacy or timing. Unless a serious complication occurs, surgery is usually delayed until after a course of antimicrobial therapy. To find out whether earlier surgery might benefit some high-risk IE patients, investigators in Korea randomized 76 adults (mean age, 47; 67% men) with left-sided IE, severe native valve disease, and large vegetations, and without an indication for urgent surgery, to surgery within the subsequent 48 hours or conventional treatment. Forty-five patients had mitral valve involvement, 22 had aortic valve involvement, and 9 had involvement of both valves. Median vegetation diameter was 12 mm.
During follow-up (median, 749 days), 30 of 39 patients assigned to conventional treatment underwent surgery, 27 during the initial hospitalization. A total of four deaths occurred, two (both noncardiac) in the early-surgery group and two (one noncardiac, one cardiac) in the conventional-treatment group. The primary endpoint — in-hospital death or embolic event within 6 weeks after randomization — occurred in 1 patient in the early-surgery group and 9 in the conventional-treatment group (P=0.03). At 6 months, all-cause mortality did not differ significantly between the two groups (early surgery, 3%; conventional treatment, 5%), but the rate of the composite of death from any cause, embolic event, recurrence of IE, and hospitalization for congestive heart failure was 3% in the early-surgery group, compared with 28% in the conventional-treatment group.
Kang D-H et al. Early surgery versus conventional treatment for infective endocarditis. N Engl J Med 2012 Jun 28; 366:2466.
Gordon SM and Pettersson GB. Native-valve infective endocarditis — When does it require surgery? N Engl J Med 2012 Jun 28; 366:2519.
Comment
In this randomized trial, early surgery significantly reduced the rate of embolic events in patients with infective endocarditis, valvular dysfunction, and large vegetations. As an editorialist notes, the time to surgery is reported from randomization but not from diagnosis of IE or the onset of symptoms, so the optimal timing of surgical intervention remains unclear. Moreover, the trial was essentially a small, single-center study; one hopes that this novel and excellent investigation prompts further clinical trials of surgery in patients with IE to generate much-needed data regarding this population's often difficult management issues. For now, early involvement of a cardiac surgeon is warranted in the care of patients at high risk for embolism.