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Original Articles: Adult Cardiac

Invited Commentary

Cardiovascular Surgery, Hospital Clinico, Villarroel 170, Barcelona 08036, Spain

(Email: cmestres{at}clinic.ub.es).

Despite many therapeutic efforts, surgery for active infective endocarditis represents a risky situation. The decision-making process is complex; the heterogeneous nature of the disease and its surgical treatment frequently make the choice of appropriate treatment difficult. Regardless of the valve location, the patient's general condition influences the choice of the best treatment option. The extent of the valve and perivalve lesions and the technical challenges of reconstruction define the problems and affect periprocedural mortality, even in the best hands.

The paper by Hill and colleagues [1] addresses a controversial and unsolved issue: timing an operation in the acute setting of active infective endocarditis. In their experience, surgery performed within 7 days after the diagnosis is associated with higher mortality. Septic shock and S. aureus infection are the most important factors affecting mortality. Patients in shock had early mortality of 57%. Most of the patients died within the first 45 days; this suggests that deaths occurred in hospital. Hill and coworkers [1] are commended for honest reporting; usually poor figures are not reported when institutions are compared.

Sample size, discussion on 6-month mortality rather than periprocedural mortality, and failure to stratify by valve position are important limitations. Nevertheless, this paper calls attention to decision making. Shock is usually septic and augments acute valve dysfunction and primarily affects in-hospital mortality. Pathogens like S. aureus are extremely aggressive but other organisms like S. viridans or S. bovis may cause massive local destruction over time if there are difficulties in establishing a correct diagnosis. All factors analyzed by the authors including timing should be taken seriously. Preoperative risk stratification may define highest-risk subgroups [2]. Some papers address the need for early treatment but doubts still remain [3–6]. There will always be biases when dealing with infective endocarditis. Institutional and individual practices, pattern of referrals and uniformity in defining and reporting differ with respect to this complex disease. Despite many methodological limitations, the main message is that when systemic sepsis and heart failure develop, surgery must be performed immediately, although it may not always be successful.

	References

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1. Hill EE, Herregods M-C, Vanderschueren S, Claus P, Peetermans WE, Herijgers P. Outcome of patients requiring valve surgery during active infective endocarditis Ann Thorac Surg 2008;85:1564-1570.[Abstract/Free Full Text]
2. Mestres CA, Castro MA, Bernabeu E, et al. Preoperative risk stratification in infective endocarditis. Does the EuroSCORE model work? Preliminary results. Eur J Cardiothorac Surg 2007;32:281-285.[Abstract/Free Full Text]
3. Wang A, Pappas P, Anstrom KJ, et al. The use and effect of surgical therapy for prosthetic valve infective endocarditis: a propensity analysis of a multicenter, international cohort Am Heart J 2005;150:1086-1091.[Medline]
4. Aksoy O, Sexton DJ, Wang A, et al. Early surgery in patients with infective endocarditis: a propensity score analysis Clin Infect Dis 2007;44:364-372.[Medline]
5. Abrutyn E, Cabell CH, Fowler VG, et al. Medical treatment of endocarditis Curr Infect Dis Rep 2007;9:271-282.[Medline]
6. Lopes S, Calvinho P, de Oliveira F, Antunes M. Allograft aortic root replacement in complex prosthetic endocarditis Eur J Cardiothorac Surg 2007;32:126-130discussion 131-2.[Abstract/Free Full Text]

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Carlos A. Mestres Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Mestres, C. A. Search for Related Content PubMed PubMed Citation Articles by Mestres, C. A. Related Collections Valve disease Related Article