Is early surgery beneficial in infective endocarditis? A systematic review.

We do not know whether surgery during the active phase of infective endocarditis improves prognosis, as no randomized trial data exist. Several observational studies published recently have examined the influence of surgery on prognosis by performing a propensity score analysis. The aim of the present paper is to review these studies, in order to determine whether or not early surgery decreases mortality in adult patients with infective endocarditis. Among nine published studies, 4199 patients were included overall. The rate of surgery during the active phase of infective endocarditis ranged from 23 to 53%. Surgery was significantly beneficial in six studies (adjusted hazard ratios or odds ratios ranging from 0.27 to 0.47), neutral in two studies and without benefit in one study (hazard ratio 1.9; 95% confidence interval 1.1-3.2). Conflicting results appear to be related to differences in statistical methods. When using appropriate models, surgery is significantly associated with reduced long-term mortality. Results from these observational studies suggest that current surgical practices in infective endocarditis are beneficial in terms of long-term survival. However, we cannot conclude that surgery is beneficial and must be performed in all patients with infective endocarditis. Surgery was associated with a favourable outcome in those patients in whom infective endocarditis presentation and patient characteristics led the physicians to perform surgery. Patients who seem to benefit most from surgery are those who fulfil management guidelines (embolic event, heart failure and/or intracardiac abscess).