scholarly journals Survival benefits and optimal timing for surgical intervention for infective endocarditis

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
H L Li ◽  
Y K Tse ◽  
S Y Yu ◽  
M Z Wu ◽  
Q W Ren ◽  
...  
Keyword(s):  
Infective Endocarditis ◽  
Propensity Score ◽  
Lower Risk ◽  
Surgical Intervention ◽  
Public Institution ◽  
Early Surgery ◽  
Causative Organism ◽  
Optimal Timing ◽  
Risk Of Death ◽  
Doubly Robust Estimation

Abstract Background Surgery is often indicated in patients with infective endocarditis (IE), but the survival benefits of surgical intervention have not been validated in large-scale studies. Although previous studies appeared to support early surgical intervention, the optimal timing of intervention remains uncertain. Purpose We aim to evaluate the benefits of surgery and identify the optimal timing of surgical intervention for patients with IE. Methods From a well-validated territory-wide database in Hong Kong, all patients aged 20 or above diagnosed with incident IE from 2000–2019 were included. Patients were divided into those who received surgical intervention within 1 year of IE (surgical cohort) and those who did not (control cohort). The two cohorts were then compared using inverse probability weighting of the covariate balancing propensity score, which included demographics, comorbidities, and causative organism as covariates. Outcomes of interest include, at 1 year, all-cause death, and the development of complications. A Cox proportional hazards model was used to evaluate the association between surgical intervention and death, with “doubly-robust estimation” used to minimise the effect of confounders. For complications, a Fine-Gray model was used to account for competing risk. The surgical cohort was subdivided into early (≤7 days of hospitalisation) or late surgical intervention; a similar propensity score analytic approach was used to evaluate the effects of early vs. late intervention, with those who died within the 7 days excluded to ensure a fair comparison. Results A total of 5,657 patients (age 59.9±18.3 years, 37.2% females) were included, of which 930 (16.4%) received surgical intervention in 1 year. Overall, the surgical cohort had a 45% risk reduction in all-cause death (hazard ratio [HR] 0.55, 95% CI [0.46 to 0.65], P<0.001) (Figure). This association remained consistent in subgroup analysis stratified by age, sex, and causative organisms (Table 1). The surgical cohort also had a lower risk of complications, including acute kidney injury (HR 0.61, 95% CI 0.43 to 0.87, P=0.006), systemic embolism (HR 0.35 [0.23 to 0.55], P<0.001), ischaemic stroke (HR 0.37 [0.24 to 0.55], P<0.001), cardiac dysrhythmia (HR 0.79 [0.66 to 0.95], P=0.011), and pneumonia (HR 0.36 [0.26 to 0.49], P<0.001). In the surgical cohort, compared to those who had early surgery (N=181), those with delayed surgery had a lower risk of all-cause death (HR 0.58 [0.34 to 0.99], P=0.045) (Figure) and complications (Table 2) at 1 year. In those who had early surgery, patients who received ultra-early surgery (≤3 days of hospitalisation, N=104) did not have a significantly different risk of death (HR 1.19 [0.47 to 3.34], P=0.654). Conclusions Surgical intervention significantly reduced the risk of death and complications in patients with infective endocarditis. Delayed surgical intervention appeared to be more protective. FUNDunding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): The Shenzhen Key Medical DisciplineThe Sanming Project of HKU-SZH Cardiology

scholarly journals Early Surgery in Patients with Infective Endocarditis: A Propensity Score Analysis

2007 ◽  
Vol 44 (3) ◽  
pp. 364-372 ◽  
Author(s):  
O. Aksoy ◽  
D. J. Sexton ◽  
A. Wang ◽  
P. A. Pappas ◽  
W. Kourany ◽  
...  
Keyword(s):  
Infective Endocarditis ◽  
Propensity Score ◽  
Propensity Score Analysis ◽  
Early Surgery ◽  
Score Analysis

Abstract 354: The Effect Of Early Surgery on Outcomes in Infective Endocarditis- A Meta- Analysis of 25,732 Patients

2015 ◽  
Vol 8 (suppl_2) ◽  
Author(s):  
Waleed T Kayani ◽  
Najia Idrees ◽  
Salman Bandeali ◽  
Don Pham ◽  
Anam Khan ◽  
...  
Keyword(s):  
Infective Endocarditis ◽  
Surgical Intervention ◽  
Meta Analysis ◽  
Cochrane Collaboration ◽  
Quality Data ◽  
Early Surgery ◽  
All Cause Mortality ◽  
The Subject ◽  
Surgery Mortality ◽  
The Impact

Despite a rising incidence of infective endocarditis (IE), its associated mortality remains high. It is estimated that at least 30% of patients with IE undergo surgery, however data on outcomes of outcomes associated with timing of surgical intervention in this setting is limited. Existing literature mainly consists of observational studies with conflicting results, and current guidelines (ACC/ AHA and Society of Thoracic Surgeons) base recommendations largely on small retrospective studies and expert opinion. We sought to determine the effect of early surgery on outcomes after IE by performing the first comprehensive meta- analysis on the subject. A comprehensive literature search using PubMed (MEDLINE) was performed using keywords “endocarditis”, “surgery”, “mortality” and “outcome”. Early surgery was defined as surgical intervention performed during index hospitalization. Primary outcome of interest was all-cause mortality. Secondary outcomes included incidence of recurrent endocarditis and embolic phenomenon. Of 117 identified studies, 36 met the inclusion criteria (25,732 patients). Data on baseline characteristics and outcomes of interest were extracted. Meta-analysis was performed using Review Manager Version 5.0 (Cochrane Collaboration). Effect sizes for outcomes of interest were estimated using odds ratio (OR) and 95% confidence intervals (CI). Given the inherent heterogeneity among included studies, results from the random effects model are reported. Of the included 25,732 patients, 7,835 underwent early surgery compared to 17,537 who received conventional treatment. A significant reduction in both, short and long term mortality in patients who underwent early surgery OR 0.58 (95% CI 0.47-0.70; p = <0.001) and OR 0.49 (95% CI 0.37-0.65; p = 0.001) respectively was seen. The incidence of recurrent endocarditis or embolic phenomenon did not differ between the two groups. This is the first comprehensive meta-analysis to examine the impact of early surgery on outcomes in patients with IE. Our results indicate that early surgery is associated with a significant reduction in all-cause mortality in patients with IE, without an increase in incidence of recurrent endocarditis. These findings are of clinical significance given paucity of quality data on the subject.

scholarly journals Early combination of albumin with crystalloids administration might be beneficial for the survival of septic patients: a retrospective analysis from MIMIC-IV database

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Shiyu Zhou ◽  
Zhenhua Zeng ◽  
Hongxia Wei ◽  
Tong Sha ◽  
Shengli An
Keyword(s):  
Intensive Care ◽  
Propensity Score ◽  
Lower Risk ◽  
Primary Outcome ◽  
Medical Information ◽  
Combination Group ◽  
Optimal Timing ◽  
Mean Survival Time ◽  
Restricted Mean Survival Time ◽  
Combined Administration

Abstract Background Fluid therapy is a cornerstone in the treatment of sepsis. Recently, the guidelines have recommended the combined administration that using crystalloids plus albumin for septic patients, but the optimal timing for albumin combined is still unclear. The objective of this study was to investigate the association of timing of albumin combined with 28-day mortality in patients with sepsis. Methods We involved septic patients from the Medical Information Mart for Intensive Care (MIMIC)-IV database, and these patients were categorized into crystalloids group (crystalloids alone) and early combination group (crystalloids combined albumin at 0–24 h). The primary outcome was 28-day mortality. We used propensity score matching (PSM) to adjust confounding and restricted mean survival time (RMST) analysis was conducted to quantify the beneficial effect on survival due to the combination group. Results We categorized 6597 and 920 patients in the “crystalloids alone” and “early combination”, respectively. After PSM, compared to the crystalloids group, the combination group was associated with the increased survival among 28-day (increased survival: 3.39 days, 95% CI 2.53–4.25; P < 0.001) after ICU admission. Patients who received albumin combination at the first 24-h was associated with prolonged LOS in ICU (10.72 days vs. 8.24 days; P < 0.001) but lower risk of 28-day mortality (12.5% vs 16.4%, P = 0.003) than those received crystalloids alone. Conclusion In septic patients, receiving albumin combined within the first 24-h after crystalloids administration was associated with an increment of survival in 28 days.

Impact of hospital teaching status on stage I pancreatic cancer survival.

2018 ◽  
Vol 36 (4_suppl) ◽  
pp. 257-257
Author(s):  
Andy Chan ◽  
Zachary K. Masuda ◽  
Ryan W Walters ◽  
Peter T. Silberstein ◽  
Sarah J Aurit
Keyword(s):  
Pancreatic Cancer ◽  
Lower Risk ◽  
Surgical Intervention ◽  
Stage I ◽  
Community Based ◽  
Partial Pancreatectomy ◽  
Risk Of Death ◽  
Academic Hospitals ◽  
Teaching Status ◽  
Facility Type

257 Background: Burke et al. (2017) revealed that academic hospitals had lower patient mortality rates for common conditions compared to community-based hospitals. We conducted a retrospective study to compare survival of Stage I pancreatic cancer patients in academic versus community-based hospitals throughout the US. Methods: We identified 6,276 patients with single primary Stage IA or IB adenocarcinoma of the pancreas from the NCDB diagnosed from 2004-2012. We only included those who had a partial pancreatectomy, Whipple procedure, or no surgical intervention. In this subset, treatment was classified as none, chemotherapy, radiation, or chemoradiation; we examined the number of days from diagnosis to treatment. Unadjusted survival stratified by facility type was estimated with the Kaplan-Meier method; multivariable Cox regression was used to adjust for patient and facility level characteristics. Results: The log-rank test indicated that survival for patients who received treatment from an academic facility was significantly longer than those treated at a community-based facility (p < 0.001). After adjusting for patient and facility characteristics, however, survival was no longer significantly associated with facility type (p = 0.52). Holding all else constant, patients who underwent a surgical intervention had a lower risk of death (HR = 0.44, 95% CI: 0.40 to 0.48). Chemoradiation had a lower risk than both radiation (HR = 0.75, 95% CI: 0.65 to 0.86) and chemotherapy (HR = 0.88, 95% CI: 0.82 to 0.95). Risk of death was increased for older males, those without private insurance, and patients with Stage IB adenocarcinoma. Conclusions: In the largest study examining the association between hospital teaching status and Stage I pancreatic cancer mortality, our data suggests that there is not a significantly lower mortality rate for patients at academic hospitals compared to patients at community-based hospitals. [Table: see text]

A Meta-Analysis of Early versus Delayed Surgery for Valvular Infective Endocarditis Complicated by Embolic Ischemic Stroke

2016 ◽  
Vol 11 (3) ◽  
pp. 187-192 ◽  
Author(s):  
Christos G. Mihos ◽  
Andres M. Pineda ◽  
Orlando Santana
Keyword(s):  
Ischemic Stroke ◽  
Infective Endocarditis ◽  
Operative Mortality ◽  
Meta Analysis ◽  
Early Surgery ◽  
Optimal Timing ◽  
Delayed Surgery ◽  
Increased Risk ◽  
Time Of Operation ◽  
Risk Ratios

Objective An embolic ischemic stroke occurs in 10% to 40% of patients with valvular infective endocarditis (IE) and confers significant morbidity. The optimal timing of valve surgery in this population is not well defined. Methods With the use of PubMed, EMBASE, Ovid, and Cochrane databases, a systematic review identified 14 studies through October 2015 that compared early versus delayed surgery for valvular IE complicated by an ischemic stroke. Early surgery was defined as 3 days or less in one, 7 days or less in eight, and 14 days or less in five studies. Risk ratios (RRs) were calculated by the Mantel-Haenszel method under a fixed- or random-effects model, for the outcomes of perioperative stroke, operative mortality, and 1-year survival. Results A total of 833 patients (early surgery, 330; delayed surgery, 503) were included. The majority of operations were for aortic and/or mitral valve IE, with prosthetic valve IE present in 0% to 60%. Infection with Staphylococcus aureus ranged from 19% to 66%, and heart failure prevalence at the time of operation was 24% to 66%. Early surgery was associated with an increased risk of operative mortality (RR, 1.72; 95% confidence interval [CI], 1.27–2.34; P = 0.0005), which was significant regardless of surgery within the first 7 days (RR, 2.19; 95% CI, 1.45–3.31; P = 0.0002) or 14 days (RR, 1.72; 95% CI, 1.12–2.64; P = 0.01) after stroke. Surgical timing did not affect the risk of perioperative ischemic or hemorrhagic stroke or 1-year survival. Conclusions In patients with valvular IE complicated by ischemic stroke, early surgery is associated with an increased risk of operative mortality, with no observed benefit in 1-year survival.

scholarly journals Optimal timing for early surgery in infective endocarditis: a meta-analysis

2015 ◽  
Vol 22 (3) ◽  
pp. 336-345 ◽  
Author(s):  
Fuxiang Liang ◽  
Bing Song ◽  
Ruisheng Liu ◽  
Liu Yang ◽  
Hanbo Tang ◽  
...  
Keyword(s):  
Infective Endocarditis ◽  
Meta Analysis ◽  
Early Surgery ◽  
Optimal Timing

scholarly journals Early Laparoscopic Ileal Resection for Localized Ileocecal Crohn’s Disease: Hard Sell or a Revolutionary New Norm?

2021 ◽  
pp. 1-8
Author(s):  
Beatriz Yuki Maruyama ◽  
Christopher Ma ◽  
Remo Panaccione ◽  
Paulo Gustavo Kotze
Keyword(s):  
Crohn’S Disease ◽  
Crohn's Disease ◽  
Medical Therapy ◽  
Surgical Intervention ◽  
Management Plan ◽  
Early Surgery ◽  
Optimal Timing ◽  
Complication Rates ◽  
Advantages And Disadvantages ◽  
Stoma Formation

<b><i>Background:</i></b> Despite reductions in surgical rates that have been observed with earlier use of biological therapy, surgery still constitutes an important tool in the therapeutic armamentarium in Crohn’s disease (CD), particularly in patients with stenotic and penetrating phenotypes. In these scenarios, early surgical intervention is recommended, as bowel damage is present and irreversible, leading to lower efficacy with biologics. <b><i>Summary:</i></b> The concept of early surgery in CD supposes the possible advantages of better surgical outcomes in luminal CD after initial resection. Optimal timing of surgical intervention is associated with better postoperative outcomes, whilst delays can lead to more technically difficult and extensive procedures, which may result in an increase in postoperative complication rates and higher rates of stoma formation. Furthermore, data from the LIR!C trial have demonstrated that early surgery in luminal localized inflammatory ileocecal CD is an adequate alternative to medical therapy, with lower societal costs in the long term. In this review, we discuss the position of early resection in ileocecal CD by critically reviewing available data, describing the ideal patients to be considered for early surgery, and weighing the potential advantages and disadvantages of an early surgery paradigm. <b><i>Key Messages:</i></b> While early surgery may not be the right choice for every patient, the ultimate decision regarding whether surgical or medical therapy should come first in the treatment paradigm must be individualized for each patient based on the disease characteristics, phenotype, risk factors, and personal preference. This highlights the importance of the multidisciplinary team, which remains a key pillar in deciding the overall management plan for patients with CD.

scholarly journals Emergency valve surgery improves clinical results in patients with infective endocarditis complicated with acute cerebral infarction: analysis using propensity score matching†

2019 ◽  
Vol 56 (5) ◽  
pp. 942-949
Author(s):  
Takaaki Samura ◽  
Daisuke Yoshioka ◽  
Koichi Toda ◽  
Ryoto Sakaniwa ◽  
Junya Yokoyama ◽  
...  
Keyword(s):  
Infective Endocarditis ◽  
Propensity Score ◽  
Cerebral Infarction ◽  
Propensity Score Matching ◽  
Clinical Results ◽  
Neurological Complications ◽  
Valve Surgery ◽  
Early Surgery ◽  
Early Group ◽  
Delayed Group

Abstract OBJECTIVES To date, the optimal timing for patients with infective endocarditis (IE) with acute cerebral infarction (CI) to undergo valve surgery is unknown. Although some previous studies have reported that early valve surgery for IE patients within 1 or 2 weeks after CI could be performed safely, an initial strategy has not been identified because of the unmatched cohorts in previous studies. This study aimed to assess the feasibility and safety of early surgery within a few days after cerebral infarction by using propensity score matching. METHODS Between 2009 and 2017, 585 patients underwent valve surgery for patients with active IE at 14 institutions. Among these, 152 had preoperative acute CI. Early surgery was defined as surgery within 3 days after the diagnosis of CI. Of these 152 patients, 67 underwent early valve surgery (early group), whereas 85 underwent delayed valve surgery (delayed group). Of the patients, 45 in each group were analysed using propensity score matching. The primary outcome was in-hospital death after valve surgery, and secondary outcomes included neurological complications. We compared the clinical results of these matched patients. RESULTS Hospital mortality was lower in the early group (2% vs 16%, P = 0.058). The rate of postoperative intracranial haemorrhage in the early and delayed groups was 4% in both groups. The postoperative modified Rankin scale was not significantly different [early group: 0 (0–2); delayed group: 0 (0–2)]. Incidence of neurological deterioration did not differ significantly between the groups. The survival rates after the first discharge at 1, 3 and 5 years after valve operation were 100%, 97% and 97% in the early group and 91%, 83% and 80% in the delayed group, respectively (P = 0.029). CONCLUSIONS Early valve surgery for patients with IE within 3 days after a CI measuring <2 cm in size improved clinical results without increasing the incidence of postoperative neurological complications.

P2757Embolic risk stratification and prognostic impact of early surgery in left-sided infective endocarditis

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
V Scheggi ◽  
N Ceschia ◽  
V Andrei ◽  
P L Stefano
Keyword(s):  
Infective Endocarditis ◽  
High Risk ◽  
Risk Stratification ◽  
Imaging Techniques ◽  
Low Risk ◽  
Early Surgery ◽  
Optimal Timing ◽  
Prognostic Impact ◽  
Telephone Interviews ◽  
Similar Survival

Abstract Background Surgery is performed in 50% to 60% of infective endocarditis. In patients with definite surgical indication for hearth failure and with large vegetation, early surgery prevents embolic events. The optimal timing of surgery for other indications is still debated. Moreover, patients with large vegetation as unique indication to surgery, have a weak class of recommendation to it. Accurate risk stratification for embolic events is desirable to optimize selection of surgical candidates. Materials and methods We retrospectively analyzed 195 consecutive patients (72 women and 123 men) admitted to our department between 2013 and 2017 with definite IE according to modified Duke University criteria. Transesophageal echocardiography and blood cultures were performed in all patients for confirmation of diagnosis. Systemic embolism was soughton admission clinically and with imaging techniques (Brain and chest CT plus abdominal CT or US scan). Seventy-seven percent of patients underwent surgery (valve repair or replacement). Outcome following discharge was systematically assessed by structured telephone interviews. Results Of the 195 patients with left sided IE, 151 underwent surgery, 29 were low risk and treated medically, 5 refused surgery and 10 were not operated due to high surgical risk. Overall survival was 78% at 4 years. Patients excluded from surgery had the worst prognosis, while operated patients with high-risk IE showed comparable survival to non-complicated infections treated medically. Early surgery (<2 weeks from diagnosis) was associated with similar survival compared to later intervention. Euroscore II was the main predictor of mortality when above a threshold of 7 before 2015 and 16 after 2015, reflecting surgical management of higher risk patients over time.In left sided IE, mean vegetation length was 11.1 mm; embolic events before diagnosis occurred in 35% of cases and Staphylococcus aureus etiologywas the main risk factor associated with embolism (OR 4, p<0.05). Vegetation size >10 mm was also independently associated with embolic risk (p=0.033) whereas renal failure, age, sex, endocarditis location (mitral or aortic), type of valve (native or prosthetic), perivalvular extension and degree of valveregurgitation were not. Conclusions Compared to low-risk IE patients treated medically, those at high-risk showed comparable survival when managed surgically, whereas a conservative approach was associated with adverse prognosis. In patients with left sided IE and intermediate vegetation length, S. aureus infection was the best independent predictor of systemic embolic events. Our data support extensive surgical referral in high risk IE and suggest that its etiology represents an important factor in decision-making.

scholarly journals Microbiology of infective endocarditis in Hong Kong from 2000 to 2019: a 20-year analysis

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
H L Li ◽  
Y K Tse ◽  
S Y Yu ◽  
M Z Wu ◽  
Q W Ren ◽  
...  
Keyword(s):  
Staphylococcus Aureus ◽  
Hong Kong ◽  
Infective Endocarditis ◽  
Antibiotic Prophylaxis ◽  
Public Institution ◽  
Risk Of Death ◽  
Microbiological Profile ◽  
Significant Change ◽  
Culture Negative ◽  
Over Time

Abstract Background Infective endocarditis (IE) is associated with high mortality and complex microbiological profile. The antibiotic prophylaxis guidelines underwent a major revision in 2009 to reduce unnecessary antibiotic exposure. Substantial geographic variations in microbiological profiles exist, of which the understanding in an Asian population is lacking. Purpose We aim to describe the trends in the microbiology of IE in Hong Kong in the past 2 decades. Methods All patients aged 20 or above diagnosed with incident IE with blood culture results from 2000–2019 were included from a well-validated territory-wide database in Hong Kong, and were classified as 7 groups of causative organisms as shown in Figure 1. To evaluate the association between microbiology and 1-year all-cause death, a multivariable Cox proportional-hazards model was used, adjusted with demographics and comorbidities. Temporal trends in the proportion of each organism were characterised using Poisson regression. Interrupted time series analysis was used to evaluate the change in the organism-specific incidence after the revision of guidelines. Results In a total of 5,657 patients (age 59.9±18.3 years, 37.2% females), there were 2,185 (38.6%) patients with culture-negative endocarditis. Staphylococcus aureus (22.4%) and Streptococci (20.5%) were the most common organisms identified. Over time, there was a significant reduction in the proportion of culture-negative endocarditis (annual percentage change [APC] −2.3% [−2.8 to −1.7], P&lt;0.001), and a significant increase in the proportion of endocarditis due to Staphylococcus aureus (APC 1.6% [0.7 to 2.4], P&lt;0.001) and Streptococci (APC 2.3% [1.4 to 3.3], P&lt;0.001) (Figure 1). After guidelines revision in 2009, there was no significant change in organism-specific incidence (all P-values for relative change&gt;0.05). Compared to patients with culture-negative endocarditis, those infected with Staphylococcus aureus (hazard ratio [HR] 2.19 [1.94–2.47], P&lt;0.001), other Staphylococci (HR 1.56 [1.20–2.01], P&lt;0.001), Enterococci (HR 1.60 [1.25–2.05], P&lt;0.001), other microorganisms (HR 1.30 [1.05–1.60], P=0.015), and mixed microorganisms (HR 2.40 [2.02–2.84], P&lt;0.001) had a higher risk of 1-year all-cause death (Figure 2). There was a significant increase in the proportion of methicillin-resistant Staphylococcus aureus (MRSA) endocarditis (APC 4.1% [1.9 to 6.3], P&lt;0.001), with no significant interval change after 2009. Patients infected with MRSA had a higher all-cause death (HR 2.00 [1.70–2.36], P&lt;0.001). Conclusions Different causative organisms carry variable mortality signals in infective endocarditis. Over time, there were fewer cases of culture-negative endocarditis, and the revision of antibiotic prophylaxis guidelines did not result in a significant change in the microbiological profile. There was an increasing trend for MRSA endocarditis, which was associated with a higher risk of death. FUNDunding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): The Shenzhen Key Medical DisciplineThe Sanming Project of HKU-SZH Cardiology

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