No abstract

N THE PREANTIBIOTIC ERA, NATIVE valve endocarditis was virtually always fatal. Since the advent of antibiotic therapy, mortality decreased to 24% to 60% in published case series, with heart failure representing the leading cause of death. [1][2][3][4] During the past 3 decades, studies have suggested that valve surgery should be considered for patients with native valve endocarditis associated with complications that adversely affect prognosis: heart failure, 5-10 new valvular regurgitation, [11][12][13] refractory infection (ie, persistent fever or bacteremia, fungemia, or paravalvular abscess), 14,15 systemic embolization to vital organs, 16,17 and the presence of a vegetation on echocardiography as this represents a plausible risk for embolization. [18][19][20] However, methodological limitations of existing studies, the absence of randomized controlled trials, and the lack of a validated method to classify prognostic severity make management decisions problematic.Accurate prognostic classification may help facilitate individual treatment decisions and interpretation of therapeutic interventions in clinical trials. In this study, we derived and externally validated a prognostic classification system in 2 contemporaneous cohorts of adults with complicated leftsided native valve endocarditis. METHODS PatientsResearch patients were identified through systematic medical record review at the 7 Connecticut hospitals where valve surgery was performed. To create and test a prognostic classification system, we divided patients into derivation and validation cohorts (FIGURE). The derivation cohort (n = 259) was assembled from adults (Ͼ16 years) in whom complicated leftsided native valve endocarditis was di-

Context Complicated, left-sided native valve endocarditis causes significant morbidity and mortality in adults. The presumed benefits of valve surgery remain unproven due to lack of randomized controlled trials.Objective To determine whether valve surgery is associated with reduced mortality in adults with complicated, left-sided native valve endocarditis. Design and SettingRetrospective, observational cohort study conducted from January 1990 to January 2000 at 7 Connecticut hospitals. Propensity analyses were used to control for bias in treatment assignment and prognostic imbalances.Patients Of the 513 adults with complicated, left-sided native valve endocarditis, 230 (45%) underwent valve surgery and 283 (55%) received medical therapy alone.Main Outcome Measure All-cause mortality at 6 months after baseline. ResultsIn the 6-month period after baseline, 131 patients (26%) died. In unadjusted analyses, valve surgery was associated with reduced mortality (16% vs 33%; hazard ratio [HR], 0.43; 95% confidence interval [CI], 0.29-0.63; PϽ.001). After adjustment for baseline variables associated with mortality (including hospital site, comorbidity, congestive heart failure, microbial etiology, immunocompromised state, abnormal mental status, and refractory infection), valve surgery remained associated with reduced mortality (adjusted HR, 0.35; 95% CI, 0.23-0.54; PϽ.02). In further analyses of 218 patients matched by propensity scores, valve surgery remained associated with reduced mortality (15% vs 28%; HR, 0.45; 95% CI, 0.23-0.86; P=.01). After additional adjustment for variables that contribute to heterogeneity and confounding within the propensity-matched group, surgical therapy remained significantly associated with a lower mortality (HR, 0.40; 95% CI, 0.18-0.91; P=.03). In this propensity-matched group, patients with moderate to severe congestive heart failure showed the greatest reduction in mortality with valve surgery (14% vs 51%; HR, 0.22; 95% CI, 0.09-0.53; P=.001). ConclusionsValve surgery for patients with complicated, left-sided native valve endocarditis was independently associated with reduced 6-month mortality after adjustment for both baseline variables associated with the propensity to undergo valve surgery and baseline variables associated with mortality. The reduced mortality was particularly evident among patients with moderate to severe congestive heart failure.

Clinical manifestations of LVADI vary on the basis of the type of infection and the causative pathogen. Mortality remained high despite combined medical and surgical intervention and chronic suppressive antimicrobial therapy. Based on clinical experiences, a management algorithm for LVADI is proposed to assist in the decision-making process.

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