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Journal club 11 July 2012


Early Surgery versus Conventional Treatment for Infective Endocarditis




The timing and indications for surgical intervention to prevent systemic embolism in
infective endocarditis remain controversial. We conducted a trial to compare clinical
outcomes of early surgery and conventional treatment in patients with infective
We randomly assigned patients with left-sided infective endocarditis, severe valve
disease, and large vegetations to early surgery (37 patients) or conventional treatment
(39). The primary end point was a composite of in-hospital death and embolic
events that occurred within 6 weeks after randomization.
All the patients assigned to the early-surgery group underwent valve surgery within
48 hours after randomization, whereas 30 patients (77%) in the conventional-treatment
group underwent surgery during the initial hospitalization (27 patients) or
during follow-up (3). The primary end point occurred in 1 patient (3%) in the earlysurgery
group as compared with 9 (23%) in the conventional-treatment group (hazard
ratio, 0.10; 95% confidence interval [CI], 0.01 to 0.82; P = 0.03). There was no
significant difference in all-cause mortality at 6 months in the early-surgery and
conventional-treatment groups (3% and 5%, respectively; hazard ratio, 0.51; 95% CI,
0.05 to 5.66; P = 0.59). The rate of the composite end point of death from any cause,
embolic events, or recurrence of infective endocarditis at 6 months was 3% in the
early-surgery group and 28% in the conventional-treatment group (hazard ratio,
0.08; 95% CI, 0.01 to 0.65; P = 0.02).
As compared with conventional treatment, early surgery in patients with infective
endocarditis and large vegetations significantly reduced the composite end point of
death from any cause and embolic events by effectively decreasing the risk of systemic


  • The selective nature of the patients was noted: hemodynamically significant valve lesions with large vegetations from largely low virulence organisms in a  group with high baseline prevalence of embolic phenomena
  • The observed composite end point difference in favor of early surgery was driven by embolic events
  • The high prevalence of clinical embolic phenomena in the conservative arm was noted
  • It remains an open question as to the management of patients with large vegetations without hemodynamically significantly valve lesion, though the second item suggests plausibility for early surgery
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