The fate of active left‐side infective endocarditis with operative indication in absence of valve surgery

Abstract

Objectives: Although the benefits of surgery in infective endocarditis (IE) are clear, an unneglectable proportion of patients do not undergo surgery despite clear operative indication. Outcomes of these patients are poorly reported. With this study, we aim to analyze patient profiles, indication for surgery, decision-making, and outcomes of patients not undergoing surgery despite contemporary surgical indications. Materials and Methods: Retrospective review of single institution database of patients with IE was done to identify patients that, although a clear surgical indication did not receive surgery. We aimed to review the most contemporary practice from June 2014 to December 2018. Only patients who were physically evaluated at our facility were included. Follow up was 100% complete. Kaplan-Meier methods were used to estimate survival and freedom from a composite outcome of death, stroke, and heart failure. Results: Of the 174 patients with surgical indication during the review period, 46 (27%) did not undergo surgery. The reasons for not pursuing surgery were varied and usually multiple, with severe brain injury and end stage liver disease between the most common. The 30-day mortality was 63%, and the estimated survival at 6 months, 1 year, and 2 years was respectively 22%, 15%, and 10%. Conclusion: The mortality of this cohort of patients is extremely high. A multidisciplinary evaluation is of paramount importance in the decision-making process with shared responsibility for denial of operative options. In a perspective of correct healthcare resources allocation an early palliative care consult may need to be considered in some of those patients.

Clinical Profile and Prognosis of Patients with Left-Sided Infective Endocarditis with Surgical Indication Who Are Not Operated

“…In our series, the proportion of patients with a surgical indication (83%) was higher than previously reported [ 4 , 5 , 10 , 11 , 12 , 14 ], probably reflecting a selection bias due to the characteristics of the participant centers, such as university hospitals that receive a substantial number of patients from other smaller centers without surgical facilities (52% in our series). The proportion of patients rejected for surgery was similar to other reported studies [ 4 , 5 , 10 , 11 , 12 , 14 , 15 ], in which it ranges between 24% [ 4 ] and 32.5% [ 15 ]. The same happens with the comparison of patients operated and rejected: non-operated patients are older, have more underlying comorbidities, worse clinical and microbiological profile and poorer outcomes than those who undergo surgery.…”

“…Besides, previous studies dealing with this subgroup of patients have methodological limitations. Most of them include a few patients [ 3 , 5 , 10 , 11 , 12 ], consider both LSIE and right-sided IE [ 3 ], or exclude prosthetic IE [ 5 ].…”

Risk scores’ performance and their impact on operative decision-making in left-sided endocarditis: a cohort study

“…However, it is acknowledged that in practice the final decision to offer surgery usually relies on the patients' condition and risk profile. We previously reported our non-operated cohort and compared it with operated patients [8]. In our experience, the estimated risk profile of patients not undergoing surgery (despite contemporary guidelines indication) was significantly lower than of those operated (EuroScore II 9.4% vs 23.3%, p < 0.007).…”

“…A total of 235 patients were evaluated at our institution with acute left-sided infective endocarditis. Data related to our patients who did not undergo CS has been published elsewhere [8]. A total of 142 patients (60%) underwent surgery and 2 patients (1.4%) were lost to follow-up.…”

“…Although indications for surgery might be clear from a structural or infective standpoint, in daily clinical practice the decision to offer CS is often challenging. Nearly a quarter of patients with surgical indication do not receive CS [1,8]. This reality may be a consequence of perceived futility or denial of operative management on the basis of a high-risk score estimate.…”