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Embolic risk stratification and prognostic impact of early surgery in left-sided infective endocarditis

  • Author Footnotes
    # Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi and University of Florence, ItalyAll authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation
    Valentina Scheggi
    Correspondence
    Corresponding Author. Cardiothoracovascular Department, Careggi University Hospital, Largo Brambilla 3, 50133, Florence, Italy
    Footnotes
    # Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi and University of Florence, Italy
    # All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation
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    Division of Cardiovascular and Perioperative Medicine
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    # Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi and University of Florence, ItalyAll authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation
    Bruno Alterini
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    # Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi and University of Florence, Italy
    # All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation
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    Division of Cardiovascular and Perioperative Medicine
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    # Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi and University of Florence, ItalyAll authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation
    Iacopo Olivotto
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    # Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi and University of Florence, Italy
    # All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation
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    Division of General Cardiology
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    # Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi and University of Florence, ItalyAll authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation
    Stefano Del Pace
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    # Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi and University of Florence, Italy
    # All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation
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    Division of General Cardiology
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  • Nicola Zoppetti
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    IFAC, National Research Council, Florence, Italy
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    # Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi and University of Florence, ItalyAll authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation
    Benedetta Tomberli
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    # Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi and University of Florence, Italy
    # All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation
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    Division of General Cardiology
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    # Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi and University of Florence, ItalyAll authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation
    Filippo Bartalesi
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    # Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi and University of Florence, Italy
    # All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation
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    Division of Infective Diseases
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    # Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi and University of Florence, ItalyAll authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation
    Lorenzo Brandi
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    # Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi and University of Florence, Italy
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    # Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi and University of Florence, ItalyAll authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation
    Nicole Ceschia
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    # Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi and University of Florence, Italy
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    Division of Cardiovascular and Perioperative Medicine
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    # Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi and University of Florence, ItalyAll authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation
    Valentina Andrei
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    # Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi and University of Florence, Italy
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    Division of Cardiovascular and Perioperative Medicine
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    # Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi and University of Florence, ItalyAll authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation
    Lorenzo Roberto Suardi
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    # Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi and University of Florence, Italy
    # All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation
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    Division of Infective Diseases
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    # Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi and University of Florence, ItalyAll authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation
    Niccolò Marchionni
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    # Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi and University of Florence, Italy
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    Division of General Cardiology
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  • Author Footnotes
    # Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi and University of Florence, ItalyAll authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation
    Pier Luigi Stefàno
    Footnotes
    # Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi and University of Florence, Italy
    # All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation
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    Division of Cardiac Surgery
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  • Author Footnotes
    # Cardiothoracovascular Department, Azienda Ospedaliero-Universitaria Careggi and University of Florence, ItalyAll authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation
Published:April 18, 2020DOI:https://doi.org/10.1016/j.ejim.2020.04.017

      HIGHLIGHTS

      • Staphylococcus Aureus infection is an independent predictor of systemic embolism.
      • Operated patients with complicated IE had a similar outcome as uncomplicated ones.
      • Survival rate was better for early compared to delayed surgery

      ABSTRACT

      Background

      In patients with left-sided infective endocarditis (IE) and heart failure associated with large vegetations, early surgery prevents embolic events. However, optimal timing of surgery for other indications is still unresolved particularly when the presence of large vegetations represents the sole indication.

      Methods

      We retrospectively analyzed 308 consecutive patients admitted to our department with definite left-sided IE. Of these patients, 243 (79%) underwent cardiac surgery (complicated IE), 34 patients with uncomplicated IE received medical treatment, 24 were not operated due to prohibitive general conditions and 7 refused surgery. Long-term follow-up was obtained by structured telephone interviews.

      Results

      During the 6-year follow-up (average 121.8 weeks ± 76), patients not operated because of general conditions or refusal had the worst prognosis, while outcome in operated patients for complicated IE was comparable to that of uncomplicated IE treated medically. Early (<2 weeks from diagnosis) surgery was associated with better survival compared to delayed surgery (HR 0.58, p = 0.23). Embolic events were detected at admission in 38% of cases; Staphylococcus Aureus etiology and vegetation size were independently associated with embolism (OR 2.4, p = 0.01; OR 1, p=0.008 respectively).

      Conclusions

      Compared to uncomplicated medically-treated patients, complicated IE showed comparable survival when managed aggressively by surgical intervention, whereas a conservative approach was associated with an adverse prognosis. Staphylococcus Aureus infection and vegetation size were independent predictors of systemic embolism. Our data support aggressive surgical management of complicated IE patients and highlight the importance of etiological characterization in clinical decision-making.

      Keywords

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