Naval Medical Center Portsmouth, Bldg 3, 1st Floor, 620 John Paul Jones Cir, Portsmouth, VA 23708, USA.
Circulation. 2010 Mar 2;121(8):1005-13. doi: 10.1161/CIRCULATIONAHA.109.864488. Epub 2010 Feb 16.
The impact of early surgery on mortality in patients with native valve endocarditis (NVE) is unresolved. This study sought to evaluate valve surgery compared with medical therapy for NVE and to identify characteristics of patients who are most likely to benefit from early surgery.
Using a prospective, multinational cohort of patients with definite NVE, the effect of early surgery on in-hospital mortality was assessed by propensity-based matching adjustment for survivor bias and by instrumental variable analysis. Patients were stratified by propensity quintile, paravalvular complications, valve perforation, systemic embolization, stroke, Staphylococcus aureus infection, and congestive heart failure. Of the 1552 patients with NVE, 720 (46%) underwent early surgery and 832 (54%) were treated with medical therapy. Compared with medical therapy, early surgery was associated with a significant reduction in mortality in the overall cohort (12.1% [87/720] versus 20.7% [172/832]) and after propensity-based matching and adjustment for survivor bias (absolute risk reduction [ARR] -5.9%, P<0.001). With a combined instrument, the instrumental-variable-adjusted ARR in mortality associated with early surgery was -11.2% (P<0.001). In subgroup analysis, surgery was found to confer a survival benefit compared with medical therapy among patients with a higher propensity for surgery (ARR -10.9% for quintiles 4 and 5, P=0.002) and those with paravalvular complications (ARR -17.3%, P<0.001), systemic embolization (ARR -12.9%, P=0.002), S aureus NVE (ARR -20.1%, P<0.001), and stroke (ARR -13%, P=0.02) but not those with valve perforation or congestive heart failure.
Early surgery for NVE is associated with an in-hospital mortality benefit compared with medical therapy alone.
早期手术对原发性心脏瓣膜心内膜炎（NVE）患者死亡率的影响尚未明确。本研究旨在评估瓣膜手术与药物治疗 NVE 的效果，并确定最有可能从早期手术中获益的患者特征。
本研究使用前瞻性、多国多中心队列研究，通过生存偏差倾向性匹配调整和工具变量分析，评估早期手术对 NVE 患者院内死亡率的影响。根据倾向性五分位数、瓣周并发症、瓣膜穿孔、全身栓塞、卒中、金黄色葡萄球菌感染和充血性心力衰竭，对患者进行分层。1552 例 NVE 患者中，720 例（46%）接受了早期手术，832 例（54%）接受了药物治疗。与药物治疗相比，早期手术可显著降低总体队列的死亡率（12.1%[87/720]与 20.7%[172/832]），且经倾向性匹配和生存偏差调整后（绝对风险降低[ARR]-5.9%，P<0.001）。通过联合工具，与早期手术相关的死亡率的工具变量调整 ARR 为-11.2%（P<0.001）。亚组分析显示，与药物治疗相比，在手术倾向性较高的患者（四分位 4 和 5 的 ARR-10.9%，P=0.002）和伴有瓣周并发症（ARR-17.3%，P<0.001）、全身栓塞（ARR-12.9%，P=0.002）、金黄色葡萄球菌 NVE（ARR-20.1%，P<0.001）和卒中（ARR-13%，P=0.02）的患者中，手术可带来生存获益，但在伴有瓣膜穿孔或充血性心力衰竭的患者中则不然。
与单纯药物治疗相比，早期手术治疗 NVE 可降低患者院内死亡率。
