title: In-hospital and 1-year mortality in patients undergoing early surgery for prosthetic valve endocarditis.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  METHODS
  Valve replacement during index hospitalization (early surgery) vs medical therapy.
  
  
  METHODS
  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
  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.
authors.affiliation: Infectious Disease Clinical Research Program, Bethesda, Maryland.
authors.forename: Tahaniyat
authors.initials: T
authors.lastname: Lalani
authors.forename: Vivian H
authors.initials: VH
authors.lastname: Chu
authors.forename: Lawrence P
authors.initials: LP
authors.lastname: Park
authors.forename: Enrico
authors.initials: E
authors.lastname: Cecchi
authors.forename: G Ralph
authors.initials: GR
authors.lastname: Corey
authors.forename: Emanuele
authors.initials: E
authors.lastname: Durante-Mangoni
authors.forename: Vance G
authors.initials: VG
authors.lastname: Fowler
authors.forename: David
authors.initials: D
authors.lastname: Gordon
authors.forename: Paolo
authors.initials: P
authors.lastname: Grossi
authors.forename: Margaret
authors.initials: M
authors.lastname: Hannan
authors.forename: Bruno
authors.initials: B
authors.lastname: Hoen
authors.forename: Patricia
authors.initials: P
authors.lastname: Muñoz
authors.forename: Hussien
authors.initials: H
authors.lastname: Rizk
authors.forename: Souha S
authors.initials: SS
authors.lastname: Kanj
authors.forename: Christine
authors.initials: C
authors.lastname: Selton-Suty
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Sexton
authors.forename: Denis
authors.initials: D
authors.lastname: Spelman
authors.forename: Veronica
authors.initials: V
authors.lastname: Ravasio
authors.forename: Marie Françoise
authors.initials: MF
authors.lastname: Tripodi
authors.forename: Andrew
authors.initials: A
authors.lastname: Wang
mesh_terms: D001021:Aortic Valve / Q000601:surgery; D004697:Endocarditis, Bacterial / Q000401:mortality* / Q000628:therapy*; D005260:Female; D005500:Follow-Up Studies; D006350:Heart Valve Prosthesis / Q000009:adverse effects*; D019918:Heart Valve Prosthesis Implantation; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000601:surgery; D057216:Propensity Score; D016016:Proportional Hazards Models; D011446:Prospective Studies; D016459:Prosthesis-Related Infections / Q000401:mortality* / Q000628:therapy*; D012042:Registries; D061665:Time-to-Treatment