• Tahaniyat Lalani, Vivian H Chu, Lawrence P Park, Enrico Cecchi, G Ralph Corey, Emanuele Durante-Mangoni, Vance G Fowler, David Gordon, Paolo Grossi, Margaret Hannan, Bruno Hoen, Patricia Muñoz, Hussien Rizk, Souha S Kanj, Christine Selton-Suty, Daniel J Sexton, Denis Spelman, Veronica Ravasio, Marie Françoise Tripodi, Andrew Wang, and International Collaboration on Endocarditis–Prospective Cohort Study Investigators.
• Infectious Disease Clinical Research Program, Bethesda, Maryland.
• JAMA Intern Med. 2013 Sep 9;173(16):1495-504.

ImportanceThere are limited prospective, controlled data evaluating survival in patients receiving early surgery vs medical therapy for prosthetic valve endocarditis (PVE).ObjectiveTo determine the in-hospital and 1-year mortality in patients with PVE who undergo valve replacement during index hospitalization compared with patients who receive medical therapy alone, after controlling for survival and treatment selection bias.Design, Setting, And ParticipantsParticipants were enrolled between June 2000 and December 2006 in the International Collaboration on Endocarditis-Prospective Cohort Study (ICE-PCS), a prospective, multinational, observational cohort of patients with infective endocarditis. Patients hospitalized with definite right- or left-sided PVE were included in the analysis. We evaluated the effect of treatment assignment on mortality, after adjusting for biases using a Cox proportional hazards model that included inverse probability of treatment weighting and surgery as a time-dependent covariate. The cohort was stratified by probability (propensity) for surgery, and outcomes were compared between the treatment groups within each stratum.InterventionsValve replacement during index hospitalization (early surgery) vs medical therapy.Main Outcomes And MeasuresIn-hospital and 1-year mortality.ResultsOf the 1025 patients with PVE, 490 patients (47.8%) underwent early surgery and 535 individuals (52.2%) received medical therapy alone. Compared with medical therapy, early surgery was associated with lower in-hospital mortality in the unadjusted analysis and after controlling for treatment selection bias (in-hospital mortality: hazard ratio [HR], 0.44 [95% CI, 0.38-0.52] and lower 1-year mortality: HR, 0.57 [95% CI, 0.49-0.67]). The lower mortality associated with surgery did not persist after adjustment for survivor bias (in-hospital mortality: HR, 0.90 [95% CI, 0.76-1.07] and 1-year mortality: HR, 1.04 [95% CI, 0.89-1.23]). Subgroup analysis indicated a lower in-hospital mortality with early surgery in the highest surgical propensity quintile (21.2% vs 37.5%; P = .03). At 1-year follow-up, the reduced mortality with surgery was observed in the fourth (24.8% vs 42.9%; P = .007) and fifth (27.9% vs 50.0%; P = .007) quintiles of surgical propensity.Conclusions And RelevanceProsthetic valve endocarditis remains associated with a high 1-year mortality rate. After adjustment for differences in clinical characteristics and survival bias, early valve replacement was not associated with lower mortality compared with medical therapy in the overall cohort. Further studies are needed to define the effect and timing of surgery in patients with PVE who have indications for surgery.

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