Preoperative coronary angiography in patients with surgery for left-sided infective endocarditis. a study from a global federated research network

Background and Aims Left-sided infective endocarditis (IE) is associated with high morbidity and mortality and frequently requires urgent valve surgery. Current guidelines recommend selective preoperative coronary angiography based on clinical risk profile, yet supporting evidence in real-world IE populations is limited and largely observational. Moreover, angiography may delay surgery and expose unstable patients to procedural and renal risks. We evaluated the association between preoperative coronary angiography and cardiovascular outcomes after surgery for left-sided IE using a large real-world cohort. Methods We conducted a retrospective cohort study using the TriNetX Global Collaborative Network, a federated platform aggregating de-identified electronic health records from >170 healthcare organizations worldwide. Adults undergoing open aortic or mitral valve surgery for IE were identified. Exposure was invasive coronary angiography within 1 month before surgery. A 1:1 propensity score–matched analysis was performed using 77 baseline variables including demographics, cardiovascular and non-cardiovascular comorbidities, medications, and laboratory parameters. The primary outcome was a composite of all-cause death, myocardial infarction (MI), stroke or thromboembolism (TE), severe heart failure (cardiogenic shock or acute pulmonary edema), or end-stage kidney disease (ESKD). Follow-up was up to 3 years. Results Among 1,546 patients undergoing surgery for left-sided IE, 453 (29%) underwent preoperative coronary angiography. After matching, 353 patients remained in each group with excellent covariate balance. During a mean follow-up of 2.0±1.2 years, the primary composite outcome occurred in 178 (17.7%) patients in the angiography group and 186 (19.1%) in the no-angiography group (hazard ratio [HR] 0.92, 95% confidence interval [CI] 0.75–1.14; p=0.44). No significant differences were observed for all-cause death (HR 0.99, 95% CI 0.71–1.37), stroke or TE (HR 1.09, 95% CI 0.60–1.97), ventricular arrhythmias or cardiac arrest (HR 1.09, 95% CI 0.74–1.60), heart failure hospitalization (HR 1.14, 95% CI 0.93–1.39), or severe heart failure events (HR 1.03, 95% CI 0.71–1.49). There was no interaction according to aortic versus mitral valve involvement. Conclusions In this large real-world cohort of patients undergoing surgery for left-sided IE, preoperative coronary angiography was not associated with improved cardiovascular outcomes. These findings question the routine use of invasive coronary angiography in this setting and support a more selective, risk-based approach pending randomized evidence.