Early Cardiac Surgery After Ischemic Stroke in Patients With Infective Endocarditis May Not Be Safe

To the Editor—We commend Barsic and investigators from the International Collaboration on Endocarditis for their important contribution [1]. Their work represents the first study that evaluates the timing of surgery after stroke in infective endocarditis (IE) with risk adjustment for differences in patient characteristics [2]. The authors concluded that the timing of surgery has no impact on in-hospital survival, although the adjusted odds ratio (OR) for mortality with early surgery (within 7 days of stroke) was 2.308 (95% confidence interval, .942–5.652; P = .065). In fact, there was a trend to a statistically significant increase in mortality. This OR could potentially, if the sample size was slightly larger, imply that early surgery is associated with higher mortality. We suggest that the authors perform additional analyses to further explore this important issue. One approach involves using propensity score analysis in the surgical cohort of IE patients with stroke similar to the methods used by our group [3] and Thuny et al [4]. Another approach would be to examine the impact of early surgery in the total cohort (medical and surgical) of IE patients with stroke similar to the method used by Kim et al [5] and after adjusting for survivor bias [6]. An OR of 2.3 raises concerns about early surgery in IE patients with stroke and should be further evaluated before early surgery is considered safe in this patient population. Potential conflicts of interest. Both authors: No reported conflicts. Both authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.