title: Reappraisal of a single-centre policy on the contemporary surgical management of active infective endocarditis.
abstract: OBJECTIVE
  We studied a contemporary cohort of adult patients treated surgically for infective endocarditis (IE) in order to evaluate the surgical approach and predictors of outcomes, in relation to the intercurrent adaptation of the 2006 ACC/AHA guidelines.
  
  
  METHODS
  One hundred and eighty-six consecutive patients operated on for active IE from August 1999 to September 2012 were reviewed retrospectively. Clinical presentation, surgical management and outcomes in the two study periods before and after January 2007 were compared (Period 1: n = 95 and Period 2: n = 91).
  
  
  RESULTS
  The mean (SD) follow-up was 4.3 (3.8) years and was 99.5% complete. Patients in Period 2 had more frequently associated coronary artery disease (31 vs 18%, P = 0.06), while the microbiology revealed more Staphylococcus species (43 vs 26%, P = 0.02), predominantly Staphylococcus aureus (31 vs 19%; P = 0.07), and less culture-negative cases (7 vs 17%; P = 0.05). The median delay between diagnosis and surgery was 7 days in Period 2 compared with 14 days in Period 1 (P = 0.001). Surgery in Period 2 included more root replacements for aortic valve endocarditis (11 vs 2%; P = 0.02) and mitral valve repairs (18 vs 5%; P = 0.01), while the use of homografts for aortic valve endocarditis was almost abandoned (1 vs 15%; P = 0.001). Hospital mortality was 13% and did not change significantly over both periods (P = 0.66). The independent predictors of hospital mortality were age (P = 0.03), female gender (P = 0.02), previous cardiac surgery (P = 0.02), preoperative serum creatinine level >2 mg/dl (P = 0.05), S. aureus infection (P = 0.02), emergent or salvage operation (P = 0.001) and concomitant coronary artery bypass grafting (P = 0.03). The 1-, 3-, 5- and 10-year survival were 84, 72, 64 and 57%, respectively. Late survival was negatively influenced by S. aureus endocarditis (P < 0.001) and peripheral vascular disease (P = 0.03), whereas associated coronary artery disease (P = 0.07) had a strong impact.
  
  
  CONCLUSIONS
  Adaptation of the 2006 ACC/AHA guidelines in the contemporary management of IE led to a shorter interval between diagnosis and surgery. Despite a more extensive and earlier operative approach, IE caused by S. aureus still remains a major determinant of early and late outcomes.
authors.affiliation: Cardiac Centre, University Hospital Gent, Gent, Belgium.
authors.forename: Frank
authors.initials: F
authors.lastname: Caes
authors.forename: Thierry
authors.initials: T
authors.lastname: Bové
authors.forename: Yves
authors.initials: Y
authors.lastname: Van Belleghem
authors.forename: Guy
authors.initials: G
authors.lastname: Vandenplas
authors.forename: Guido
authors.initials: G
authors.lastname: Van Nooten
authors.forename: Katrien
authors.initials: K
authors.lastname: François
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D001530:Belgium; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000401:mortality; D015897:Comorbidity; D004697:Endocarditis, Bacterial / Q000382:microbiology / Q000401:mortality / Q000601:surgery*; D005260:Female; D019983:Guideline Adherence; D017052:Hospital Mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'; D016730:Program Development; D015397:Program Evaluation; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012307:Risk Factors; D012737:Sex Factors; D013997:Time Factors; D061665:Time-to-Treatment; D016896:Treatment Outcome
keywords: Endocarditis; Mortality; Prognosis