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Meta-Analysis
. 2018 Apr 1;178(4):502-510.
doi: 10.1001/jamainternmed.2017.8653.

Association of Vegetation Size With Embolic Risk in Patients With Infective Endocarditis: A Systematic Review and Meta-analysis

Divyanshu Mohananey  1 , Ashley Mohadjer  1 , Gosta Pettersson  1 , Jose Navia  1 , Steven Gordon  2 , Nabin Shrestha  2 , Richard A Grimm  1 , L Leonardo Rodriguez  1 , Brian P Griffin  1 , Milind Y Desai  1
Affiliations
Meta-Analysis

Association of Vegetation Size With Embolic Risk in Patients With Infective Endocarditis: A Systematic Review and Meta-analysis

Divyanshu Mohananey et al. JAMA Intern Med. .

Abstract

Importance: Infective endocarditis is a life-threating condition with annual mortality of as much as 40% and is associated with embolic events in as many as 80% of cases. These embolic events have notable prognostic implications and have been linked to increased length of stay in intensive care units and mortality. A vegetation size greater than 10 mm has often been suggested as an optimal cutoff to estimate the risk of embolism, but the evidence is based largely on small observational studies.

Objective: To study the association of vegetation size greater than 10 mm with embolic events using meta-analytic techniques.

Data sources: A computerized literature search of all publications in the PubMed and EMBASE databases from inception to May 1, 2017, was performed with search terms including varying combinations of infective endocarditis, emboli, vegetation size, pulmonary infarct, stroke, splenic emboli, renal emboli, retinal emboli, and mesenteric emboli. This search was last assessed as being up to date on May 1, 2017.

Study selection: Observational studies or randomized clinical trials that evaluated the association of vegetation size greater than 10 mm with embolic events in adult patients with infective endocarditis were included. Conference abstracts and non-English language literature were excluded. The search was conducted by 2 independent reviewers blinded to the other's work.

Data extraction and synthesis: Following PRISMA guidelines, the 2 reviewers independently extracted data; disputes were resolved with consensus or by a third investigator. Categorical dichotomous data were summarized across treatment arms using Mantel-Haenszel odds ratios (ORs) with 95% CIs. Heterogeneity of effects was evaluated using the Higgins I2 statistic.

Results: The search yielded 21 unique studies published from 1983 to 2016 with a total of 6646 unique patients with infective endocarditis and 5116 vegetations with available dimensions. Patients with a vegetation size greater than 10 mm had increased odds of embolic events (OR, 2.28; 95% CI, 1.71-3.05; P < .001) and mortality (OR, 1.63; 95% CI, 1.13-2.35; P = .009) compared with those with a vegetation size less than 10 mm.

Conclusions and relevance: In this meta-analysis of 21 studies, patients with vegetation size greater than 10 mm had significantly increased odds of embolism and mortality. Understanding the risk of embolization will allow clinicians to adequately risk stratify patients and will also help facilitate discussions regarding surgery in patients with a vegetation size greater than 10 mm.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Desai reports being supported by the Haslam Family Endowed Chair in Cardiovascular Medicine and consulting for Myocardia, Inc. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. PRISMA Diagram of Search Strategy for Meta-analysis
The search was last assessed as being up to date on May 1, 2017. TTE indicates 2-dimensional transthoracic echocardiography. aTwo studies were added after manual review.
Figure 2.
Figure 2.. Forest Plot for Comparative Odds of Embolic Events
Data are stratified by vegetation size less than and greater than 10 mm. Squares represent odds ratios (ORs), with their size proportional to the weight of the study using the Mantel Haenszel test; horizontal lines, 95% CIs; diamond overall OR and 95% CI; Q, Cochrane Q statistic.
Figure 3.
Figure 3.. Forest Plot for Comparative Odds of All-Cause Mortality
Data are stratified by vegetation size less than and greater than 10 mm. Squares represent odds ratios (ORs), with their size proportional to the weight of the study using the Mantel Haenszel test; horizontal lines, 95% CIs; diamond, overall OR and 95% CI; and Q, Cochrane Q statistic.
See this image and copyright information in PMC

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