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Observational Study
. 2025 Oct 28;152(17):1221-1233.
doi: 10.1161/CIRCULATIONAHA.125.074608. Epub 2025 Aug 21.

Clinical Practice of Surgical Treatment for Left-Sided Infective Endocarditis: Nationwide Data from the NIDUS Registry

Peter Laursen Graversen  1 , Lauge Østergaard  1 , Katra Hadji-Turdeghal  1 , Jacob Eifer Møller  1   2   3 , Niels Eske Bruun  4   5   6 , Jonas Agerlund Povlsen  7 , Claus Moser  8   9 , Morten Smerup  10 , Peter Søgaard  6   11 , Hanne Sortsøe Jensen  11 , Ivy Susanne Modrau  12   13 , Andreas Dalsgaard Jensen  1 , Jeppe Kofoed Petersen  1 , Eva Havers-Borgersen  1 , Anna Stahl  1 , Jannik Helweg-Larsen  14 , Daniel Faurholt-Jepsen  14   5 , Henning Bundgaard  1   5 , Kasper Iversen  5   15 , Lars Køber  1   5 , Emil Loldrup Fosbøl  1   5
Affiliations
Observational Study

Clinical Practice of Surgical Treatment for Left-Sided Infective Endocarditis: Nationwide Data from the NIDUS Registry

Peter Laursen Graversen et al. Circulation. .

Abstract

Background: Surgery is an essential treatment for selected patients with infective endocarditis (IE). Despite indications for surgery, not all patients undergo surgery. Most previous IE cohorts have examined a selected group of patients from primary tertiary centers. Thus, the aims of this study were to describe the use of surgery by indication and to assess mortality in a nationwide cohort of patients with left-sided IE.

Methods: This study was an observational cohort study including patients with left-sided IE from the National Danish Endocarditis Studies (2016-2021). Patients were categorized according to the presence of surgical indications defined as a Class I indication for surgery according to the 2015 European guidelines or a vegetation ≥10 mm on the diagnostic echocardiography and whether surgery was performed. One-year mortality was assessed with the 1-Kaplan-Meier estimator and multivariable Cox regression models.

Results: Among 3017 patients, 662 (21.9%; median age, 66.9 years) underwent surgery, 655 (21.6%; median age, 75.9 years) had surgical indications but received conservative treatment, and 1700 (56.5%; median age, 76.0 years) had no surgical indications. Patients who underwent surgery had fewer comorbidities and more streptococci, whereas conservatively treated patients had more comorbidities and Staphylococcus aureus. Patients with surgical indications who did not undergo surgery had the highest in-hospital (31.8% versus 12.5% versus 15.7%; P<0.001) and 1-year (50.5% versus 17.0% versus 33.5%, P<0.001) mortality compared with patients who underwent surgery and those without indications for surgery. Multivariable Cox models confirmed these findings. High surgical risk (22.8%) was the most reported reason for withholding surgery.

Conclusions: In a nationwide consecutive cohort of patients with left-sided IE, 40% had indications for surgery according to guidelines, but only half of these underwent surgery. Surgically treated patients had the highest survival but were a decade younger, had fewer comorbidities, and had less frequent IE caused by S aureus. Thus, confounding by indication remains a limitation, and more studies are warranted to explore the management of patients at high surgical risk.

Keywords: cardiac surgical procedures; endocarditis; epidemiology; mortality; surgery.

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Conflict of interest statement

Dr Østergaard received an independent research grant from the Novo Nordisk Foundation for the study of mitral regurgitation. Dr Møller received institutional research grants from Abiomed and the Novo Nordic Foundation, received speakers fees from Abbott and Boehringer Ingelheim, and served on the Advisory Board for Boston Scientific. Dr Bruun received investigator-initiated grants from the Novo Nordisk Foundation, Augustinus Foundation, and Health Insurance Denmark, not related to this study. Dr Modrau received a research grant from the Novo Nordisk Foundation (5.9 Mill DKK) with no conflict of interest for this work. Dr Bundgaard reports lecture fees from Amgen, BMS, MSD, Pfizer, and Sanofi. Dr Køber reports speaker honorarium from AstraZeneca, Boehringer, Novartis, and Novo. Dr Fosbøl reports receiving from the Novo Nordisk Foundation and Danish Heart Association independent research grants related to valvular heart disease and endocarditis. The other authors report no conflicts.

Figures

Figure 1.
Figure 1.
Flow diagram of the study population. CIED indicates cardiac implantable electronic device; IE, infective endocarditis; and NIDUS, National Danish Endocarditis Studies.
Figure 2.
Figure 2.
Microbiological causes stratified by study groups. Bar chart displays the proportion of the primary microbiological causes stratified by study groups. BCN indicates blood culture-negative; and CoNS, coagulase-negative staphylococci.
Figure 3.
Figure 3.
Bar chart showing an overview of the indications for surgery. Bar chart displays the proportion of specific indications for surgery according to study groups 1 and 2. Veg. indicates vegetation.
Figure 4.
Figure 4.
Crude 1-year mortality (1-Kaplan-Meier estimator) stratified by indications for surgery and treatment choice. The 1-Kaplan-Meier (KM) estimator (est) for 1-year crude all-cause mortality rates stratified by study group. In the top right-hand corner, the 1-KM estimates with 95% CIs are presented at 1 year. Note that patients who underwent surgery were followed up from the date of surgery compared with the other 2 groups who were followed up from the date of infective endocarditis diagnosis.
See this image and copyright information in PMC

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