Duke University Medical Center, Durham, NC, USA.
Department of Cardiology, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark.
Eur Heart J. 2019 Jul 14;40(27):2243-2251. doi: 10.1093/eurheartj/ehz204.
In left-sided infective endocarditis (IE), a large vegetation >10 mm is associated with higher mortality, yet it is unknown whether surgery during the acute phase opposed to medical therapy is associated with improved survival. We assessed the association between surgery and 6-month mortality as related to vegetation size.
Patients with definite, left-sided IE (2008-2012) from The International Collaboration on Endocarditis prospective, multinational registry were included. We compared clinical characteristics and 6-month mortality (by Cox regression with inverse propensity of treatment weighting) between patients with vegetation size ≤10 mm vs. >10 mm in maximum length by surgical treatment strategy. A total of 1006 patients with left sided IE were included; 422 with a vegetation size ≤10 mm (median age 66.0 years, 33% women) and 584 (median age 58.4 years, 34% women) patients with a large vegetation >10 mm. Operative risk by STS-IE score was similar between groups. Embolic events occurred in 28.4% vs. 44.3% (P < 0.001), respectively. Patients with a vegetation >10 mm was associated with higher 6-month mortality (25.1% vs. 19.4% for small vegetation, P = 0.035). However, after propensity adjustment, the association with higher mortality persisted only in patients with a large vegetation >10 mm vs. ≤10 mm: hazard ratio (HR) 1.55 (1.27-1.90); but only in patients with large vegetation managed medically [HR 1.86 (1.48-2.34)] rather than surgically [HR 1.01 (0.69-1.49)].
Left-sided IE with vegetation size >10 mm was associated with an increased mortality at 6 months in this observational study but was dependent on treatment strategy. For patients with large vegetation undergoing surgical treatment, survival was similar to patients with smaller vegetation size.
在左侧感染性心内膜炎（IE）中，大于 10mm 的大赘生物与更高的死亡率相关，但尚不清楚急性期间手术与药物治疗相比是否与生存率的提高相关。我们评估了手术与赘生物大小相关的 6 个月死亡率之间的关系。
纳入了 2008 年至 2012 年期间来自国际心内膜炎协作前瞻性、多中心注册的明确的左侧 IE 患者。我们比较了两种手术治疗策略下，赘生物大小≤10mm 与>10mm 的患者的临床特征和 6 个月死亡率（采用逆倾向治疗加权的 Cox 回归）。共纳入 1006 例左侧 IE 患者，其中 422 例赘生物大小≤10mm（中位年龄 66.0 岁，33%为女性），584 例赘生物大小>10mm（中位年龄 58.4 岁，34%为女性）。两组患者 STS-IE 评分的手术风险相似。栓塞事件分别发生在 28.4%和 44.3%（P<0.001）。赘生物大小>10mm 与较高的 6 个月死亡率相关（小赘生物组为 25.1%，大赘生物组为 19.4%，P=0.035）。然而，经过倾向评分调整后，仅在大赘生物>10mm 与≤10mm 的患者中，与更高死亡率相关的关联仍然存在：风险比（HR）1.55（1.27-1.90）；但仅在大赘生物接受药物治疗的患者中[HR 1.86（1.48-2.34）]，而不是手术治疗的患者中[HR 1.01（0.69-1.49）]。
在这项观察性研究中，左侧 IE 患者的赘生物大小>10mm 与 6 个月时的死亡率增加相关，但与治疗策略有关。对于接受手术治疗的大赘生物患者，其生存率与赘生物较小的患者相似。
