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

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. Surgical patients had fewer comorbidities and more streptococci, whereas nonsurgical 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 surgical patients and those without indications. 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: endocarditis; epidemiology; mortality; surgery.