From structural heart lesions to host burden: changing epidemiology and outcomes of native valve infective endocarditis, a nationwide study, 2006–2023

Q: What are the key findings of this study?

Surgery for native valve infective endocarditis significantly reduces mortality across all age groups, with persistent benefits in elderly patients.

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: native valve infective endocarditis (n=18402). Intervention: Valve surgery vs. Medical therapy. Primary outcome: In-hospital all-cause mortality and 5-year all-cause mortality (HR 0.51, 95% CI 0.39-0.66, p=<0.001).

Q: What does this research mean for the field?

Surgery for native valve infective endocarditis significantly reduces mortality across all age groups, with persistent benefits in elderly patients. Novelty: ClaimNovelty.CONFIRMATORY. Consensus alignment: ConsensusAlignment.SUPPORTS_CONSENSUS.

Q: What question did this study set out to answer?

To evaluate nationwide temporal trends, mortality predictors, and the survival impact of valve surgery across age groups in patients hospitalized with native valve infective endocarditis.

YR Kim; Mi‐Jeong Kim; Jungkuk lee; Kyung An Kim; Hae Ok Jung; Jeong Seob Yoon; Doo Soo Jeon

doi:10.1136/openhrt-2025-003764

January 1, 2026Open HeartOpen Access

From structural heart lesions to host burden: changing epidemiology and outcomes of native valve infective endocarditis, a nationwide study, 2006–2023

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Key result

Native valve infective endocarditis surgery is linked to ~49% lower mortality vs. medical therapy.

HR 0.51
95% CI 0.39-0.66
P<0.001
n=18,402

Figures

Why the study?

The epidemiology of native valve infective endocarditis has shifted toward older adults with significant comorbidity burdens, but contemporary nationwide data on outcomes and surgical impact remain limited.

Does valve surgery reduce mortality in adult patients hospitalized with native valve infective endocarditis compared to medical therapy alone?

Key Points

To evaluate nationwide temporal trends, mortality predictors, and the survival impact of valve surgery across age groups in patients hospitalized with native valve infective endocarditis.
Nationwide cohort study of 18,402 adult patients hospitalized with native valve infective endocarditis in Korea between 2006 and 2023, with a median follow-up of 2.7 years (IQR 1.2–7.7).
Assessed in-hospital mortality, 5-year all-cause mortality, relapse, and surgical timing (early ≤7 days vs late >7 days) using multivariable Cox models, propensity score-matched landmark analyses, and restricted cubic splines.
Overall in-hospital mortality was 25.5%, and 5-year survival was 70.5% in patients <65 years compared with 34.4% in those ≥65 years, with overall 5-year mortality exceeding 50%.
Valve surgery was performed in 29.1% of patients, and both early (≤7 days) and late (>7 days) surgery were associated with significantly lower mortality than medical therapy alone (all p<0.001).
Surgery was associated with significantly fewer composite events of death or relapse across age groups (Mantel-Haenszel χ²=80.9, p<0.001), showing preserved relative survival benefit without an age-by-treatment interaction.

Study Design

Type

Cohort (n=18,402)

Multicenter

Yes

Structured PICO

Does valve surgery reduce mortality in adult patients hospitalized with native valve infective endocarditis compared to medical therapy alone?

P

Population

n=18,402 adult patients (≥18 years) hospitalized with a primary diagnosis of native valve infective endocarditis (IE) at general hospitals with >100 beds in Korea. Excluded: history of prosthetic valve replacement or transcatheter aortic valve replacement. Mean age 63.7 years, 51.8% male.

I

Intervention

Valve surgery (performed in 29.1% of patients, including early ≤7 days and late >7 days)

C

Comparator

Medical therapy alone

O

Outcome

In-hospital all-cause mortality and long-term all-cause mortality up to 5 years after the index admissionhard clinical

Main Result

Effect estimate: HR 0.51 (95% CI 0.39-0.66)

p-value: p=<0.001

In a nationwide Korean cohort, native valve infective endocarditis has shifted toward an older, multimorbid population with high mortality, but valve surgery remains associated with a significant survival benefit across all age groups.

Limitations

Absence of detailed surgical information
Microbiological data lacking
Limited ability to assess individual surgical candidacy
Potential misclassification of antibiotic data
External validity limited due to exclusion of prosthetic valve cases
Administrative claims-based design lacking detailed surgical information (valve position, prosthesis type)
Unmeasured confounding such as frailty or patient preference
Lack of direct microbiological data (antibiotics used as surrogate)
Lack of outcomes like readmission, reinfection, and quality of life
Exclusion of prosthetic valve endocarditis limits external validity
Inability to determine specific clinical or anatomical indications for surgery

Implication

Surgery associated with lower mortality across ages in native valve IE; extends observational consensus but leaves causal benefit open for RCTs.

Abstract

Background The epidemiology of native valve infective endocarditis (IE) has shifted toward older adults with substantial comorbidity burdens, yet contemporary nationwide data on outcomes and surgical impact remain limited. Methods We conducted an 18-year nationwide cohort study of adults hospitalised with native valve IE in Korea (2006–2023). Outcomes included in-hospital and 5-year all-cause mortality, IE relapse and a composite of death or relapse. Temporal trends, mortality predictors and surgical associations across age strata were evaluated using multivariable Cox models and stratified survival analyses. Results Among 18 402 patients (mean age 63.7 years), incidence declined in individuals <45 years but increased in those ≥65 years. In-hospital mortality was 25.5%, and 5-year mortality exceeded 50% overall. Advanced age, dialysis dependence, cancer and major complications predicted mortality. Valve surgery, performed in 29.1% of patients, was consistently associated with lower short- and long-term mortality across age groups, with no evidence of age-by-treatment interaction. Both early (≤7 days) and late (>7 days) surgery showed reduced mortality versus medical therapy. IE relapse was more frequent in older adults, and surgery was associated with a lower relapse risk. In the composite outcome of death or relapse, older adults had a higher event burden, whereas surgery remained associated with fewer composite events. Conclusions Native valve IE in Korea has shifted toward an elderly, multimorbid population with persistently high mortality. Despite declining utilisation, the survival benefit of surgery was preserved across the age spectrum, supporting operative consideration in appropriately selected older adults.

Discussion

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Cite This Study

Kim et al. (2026) conducted a cohort in native valve infective endocarditis (n=18,402). Valve surgery vs. Medical therapy was evaluated on In-hospital all-cause mortality and 5-year all-cause mortality (HR 0.51, 95% CI 0.39-0.66, p=<0.001). Surgery for native valve infective endocarditis significantly reduces mortality across all age groups, with persistent benefits in elderly patients.

synapsesocial.com/papers/6963220591e05aa366cb8684 https://doi.org/10.1136/openhrt-2025-003764

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From structural heart lesions to host burden: changing epidemiology and outcomes of native valve infective endocarditis, a nationwide study, 2006–2023

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

From structural heart lesions to host burden: changing epidemiology and outcomes of native valve infective endocarditis, a nationwide study, 2006–2023

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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