SURGICAL TIMING FOR INFECTIVE ENDOCARDITIS


Duk-Hyun Kang, M.D., Asan Medical Center, Seoul, South Korea

Despite advances in medical and surgical treatment, infective endocarditis (IE) remains a serious disease that carries considerable mortality and morbidity. The role of surgery has been expanding in IE and early surgery is strongly indicated for IE patients with congestive heart failure or uncontrolled infection, but no randomized trial has been conducted to clarify the indications and optimal timing of surgery because of ethical, logistical and financial constraints.

Early Surgery versus Conventional Treatment in Infective Endocarditis (EASE) trial was designed to compare clinical outcomes of early surgery and conventional treatment strategy for IE patients with a high risk of embolism. Patients with left-sided IE, severe valve disease and large vegetation were randomly assigned on a 1:1 basis to early surgery (37 patients) or to conventional treatment (39 patients). The primary end point was a composite of in-hospital death and embolic events that occurred within 6 weeks from randomization. The primary end point occurred in 1 (2.7%) patient of the early surgery group and in 9 (23.1%) of the conventional treatment group (hazard ratio [HR], 0.248; 95% confidence interval [CI], 0.069-0.883; P=0.031).

The EASE trial demonstrated that early surgery performed within 48 hours after diagnosis reduced the primary end point of death and embolic events by effectively decreasing systemic embolisms in patients with IE. Moreover, these improvements in clinical outcomes could be achieved without increase in operative mortality or recurrence of IE. Additional larger randomized trials are needed to evaluate the effectiveness of early surgery in complicated IE.