Cardiovascular Medicine, Careggi University Hospital, Florence, Italy
Cardiology, Amiens University Hospital, Amiens, France.
Heart. 2023 Jul 27;109(16):1248-1253. doi: 10.1136/heartjnl-2023-322391.
The best strategy to manage patients with left-sided infective endocarditis (IE) and intermediate-length vegetations (10-15 mm) remains uncertain. We aimed to evaluate the role of surgery in patients with intermediate-length vegetations and no other European Society of Cardiology guidelines-approved surgical indication.
We retrospectively enrolled 638 consecutive patients admitted to three academic centres (Amiens, Marseille and Florence University Hospitals) between 2012 and 2022 for left-sided definite IE (native or prosthetic) with intermediate-length vegetations (10-15 mm). We compared four clinical groups: medically (n=50) or surgically (n=345) treated complicated IE, medically (n=194) or surgically (n=49) treated uncomplicated IE.
Mean age was 67±14 years. Women were 182 (28.6%). The rate of embolic events on admission was 40% in medically treated and 61% in surgically treated complicated IE, 31% in medically treated and 26% in surgically treated uncomplicated IE. The analysis of all-cause mortality showed the lowest 5-year survival rate for medically treated complicated IE (53.7%). We found a similar 5-year survival rate for surgically treated complicated IE (71.4%) and medically treated uncomplicated IE (68.4%). The highest 5-year survival rate was observed in surgically treated uncomplicated IE group (82.4%, log-rank p<0.001). The analysis of the propensity score-matched cohort estimated an HR of 0.23 for uncomplicated IE treated surgically compared with medical therapy (p=0.005, 95% CI: 0.079 to 0.656).
Our results suggest that surgery is associated with lower all-cause mortality than medical therapy in patients with uncomplicated left-sided IE with intermediate-length vegetations even in the absence of other guideline-based indications.
对于左侧感染性心内膜炎（IE）且赘生物长度处于中等范围（10-15mm）的患者，最佳的治疗策略仍不确定。本研究旨在评估对于赘生物长度处于中等范围且无其他欧洲心脏病学会指南推荐手术适应证的患者，手术的作用。
我们回顾性纳入了 2012 年至 2022 年期间在三个学术中心（亚眠、马赛和佛罗伦萨大学医院）因左侧明确 IE（原生或人工）且赘生物长度处于中等范围（10-15mm）而住院的 638 例连续患者。我们比较了四个临床组：接受药物（n=50）或手术（n=345）治疗的复杂 IE 患者、接受药物（n=194）或手术（n=49）治疗的简单 IE 患者。
患者的平均年龄为 67±14 岁，女性占 182 例（28.6%）。药物治疗的复杂 IE 患者和手术治疗的复杂 IE 患者入院时栓塞事件的发生率分别为 40%和 61%，药物治疗的简单 IE 患者和手术治疗的简单 IE 患者的发生率分别为 31%和 26%。全因死亡率分析显示，药物治疗的复杂 IE 患者的 5 年生存率最低（53.7%）。我们发现，手术治疗的复杂 IE（71.4%）和药物治疗的简单 IE（68.4%）的 5 年生存率相似。手术治疗的简单 IE 患者的 5 年生存率最高（82.4%，log-rank p<0.001）。倾向评分匹配队列的分析估计，与药物治疗相比，手术治疗的简单 IE 的 HR 为 0.23（p=0.005，95%CI：0.079 至 0.656）。
我们的结果表明，对于赘生物长度处于中等范围且无其他指南推荐手术适应证的左侧简单 IE 患者，手术治疗与药物治疗相比，全因死亡率更低。
