What is the clinical evidence from this study?

Study design: Cohort. Population: Infective endocarditis (IE) undergoing surgical treatment (n=1767). Intervention: Age ≥75 years vs. Age <60 years. Primary outcome: 90-day all-cause mortality (HR 2.47, 95% CI 1.88-3.24, p=<0.001).

September 25, 2020Open Access

Differences in mortality in patients undergoing surgery for infective endocarditis according to age and valvular surgery

Q: What are the key findings of this study?

In patients undergoing surgery for infective endocarditis, age ≥75 years was associated with a significantly higher 90-day mortality compared to age <60 years (HR 2.47).

Key Result

In patients undergoing surgery for infective endocarditis, age ≥75 years was associated with a significantly higher 90-day mortality compared to age <60 years (HR 2.47).

Study Design

Type

Cohort (n=1,767)

Multicenter

Yes

Structured PICO

Does older age and complex left-sided valvular surgery increase mortality in patients undergoing surgery for infective endocarditis?

Population

1,767 patients with first-time infective endocarditis (IE) undergoing surgical treatment, median age 63, 26.7% female, based in Denmark.

Intervention

Older age (60-75 years and ≥75 years) and complex left-sided surgical intervention (mitral valve surgery or a combination of mitral and aortic valve surgery)

Comparator

Age <60 years and isolated aortic valve surgery

Outcome

All-cause mortality 90 days after valve surgeryhard clinical

In patients undergoing surgery for infective endocarditis, mortality increases significantly with age and complexity of valve surgery, with 1 in 5 patients over 75 dying within 90 days.

Main Result

Effect estimate: HR 2.47 (95% CI 1.88-3.24)

Absolute Event Rate: 22.3% vs 7.5%

p-value: p=<0.001

Limitations

No data from echocardiography to characterize the infectious spread on cardiac structures
Data on the indication of surgery and microbiological etiology was not accessible from the registries used
Residual confounding may exist despite multivariable adjustment

Abstract

BACKGROUND: Infective endocarditis (IE) is associated with high mortality. Surgery may improve survival and reduce complications, but the balance between benefit and harm is difficult and may be closely related to age and type of surgical intervention. We aimed to examine how age and type of left-sided surgical intervention modified mortality in patients undergoing surgery for IE. METHODS: By crosslinking nationwide Danish registries we identified patients with first-time IE undergoing surgical treatment 2000-2017. Patients were grouped by age 75 years, respectively. Mortality at 90 days were 7.5, 13.9, and 22.3% (p < 0.001) for three age groups. In adjusted analyses, patients 60-75 years and patients ≥75 years were associated with a higher mortality, HR = 1.84 (95% CI: 1.48-2.29) and HR = 2.47 (95% CI: 1.88-3.24) as compared with patients < 60 years. Factors associated with 90-day mortality were: mitral valve surgery, a combination of mitral and aortic valve surgery as compared with isolated aortic valve surgery, age, diabetes, and prosthetic heart valve implantation prior to IE admission. CONCLUSIONS: In patients undergoing surgery for IE, mortality increased significantly with age and 1 in 5 died above age 75 years. Mitral valve surgery as well as multiple valve interventions augmented mortality further.

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