Aims 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. Methods and results 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)]. Conclusion 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.
Bibliographical noteFunding Information:
ICE participating sites Argentina: Liliana Clara, MD, Marisa Sanchez, MD (Hospital Italiano). Jos? Casab?, MD, PhD, Claudia Cortes, MD (Hospital Universitario de la Fundaci?n Favaloro). Francisco Nacinovich, MD, Pablo Fernandez Oses, MD, Ricardo Ronderos, MD, Adriana Sucari, MD, Jorge Thierer, MD (Instituto Cardiovascular). Javier Altclas, MD, Silvia Kogan, MD (Sanatorio de la Trinidad Mitre). Australia: Denis Spelman, MD (Alfred Hospital). Eugene Athan, MD, Owen Harris, MBBS (Barwon Health). Karina Kennedy, MBBS, Ren Tan, MBBS (Canberra Hospital). David Gordon, MBBS, PhD, Lito Papanicolas, MBBS (Flinders Medical Centre). Tony Korman, MD, Despina Kotsanas, BSc (Hons) (Southern Health). Robyn Dever, MD, Phillip Jones, MD, Pam Konecny, MD, Richard Lawrence, MD, David Rees, MD, Suzanne Ryan, MHSc (St. George Hospital). Michael P. Feneley, MD, John Harkness, MD, Phillip Jones, MD, Suzanne Ryan, MHSc (St. Vincent?s). Phillip Jones, MD, Suzanne Ryan, MHSc (Sutherland). Phillip Jones, MD, Jeffrey Post, MD, Porl Reinbott, Suzanne Ryan, MHSc (The University of New South Wales). Austria: Rainer Gattringer, MD, Franz Wiesbauer, MD (Vienna General Hospital). Brazil: Adriana Ribas Andrade, Ana Cl?udia Passos de Brito, Armenio Costa Guimar?es, MD (Ana Neri Hospital). Max Grinberg, MD, PhD, Alfredo Jos? Mansur MD, PhD, Rinaldo Focaccia Siciliano, MD, Tania Mara Varejao Strabelli, MD, Marcelo Luiz Campos Vieira, MD (Heart Institute (Incor), University of Sao Paulo Medical School). Regina Aparecida de Medeiros Tranchesi, MD, Marcelo Goulart Paiva, MD (Hospital 9 de Julho). Claudio Querido Fortes, MD, PhD (Hospital Universitario Clementino Fraga Filho/UFRJ). Auristela de Oliveira Ramos, MD (Instituto Dante Pazzanese de Cardiologia). Clara Weksler, MD, Giovanna Ferraiuoli MD, Wilma Golebiovski, MD (Instituto Nacional de Cardiologia), Cristiane Lamas, MD MRCP PhD (Unigranrio and Instituto Nacional de Cardiologia, Rio de Janeiro). Canada: James A. Karlowsky, MD, Yoav Keynan, MD, Andrew M. Morris, MD, Ethan Rubinstein, MD, LL.B (University of Manitoba). Chile: Sandra Braun Jones, MD, Patricia Garcia, MD (Hospital Cl?nico Pont. Universidad Cat?lica de Chile). M Cereceda, MD, Alberto Fica, Rodrigo Montagna Mella, Md (Hospital Clinico Universidad de Chile). Columbia: Ricardo Fernandez, MD, Liliana Franco, MD, Javier Gonzalez, MD, Astrid Natalia Jaramillo, MD (Clinica Cardiovascular Medell?n) Croatia: Bruno Barsic, MD, PhD, Suzana Bukovski, MD, PhD Vladimir Krajinovic, MD, Ana Pangercic, MD, Igor Rudez, MD, Josip Vincelj, MD, PhD (University Hospital for Infectious Diseases). Czech Republic: Tomas Freiberger, MD, PhD (Ceitec, Masaryk University, Brno) Jiri Pol, MD, Barbora Zaloudikova, MSc (Centre for Cardiovascular Surgery and Transplantation). Egypt: Zainab Ashour, MD, Amani El Kholy, MD, Marwa Mishaal, MD, Dina Osama, MD, Hussien Rizk, MD (Cairo University Medical School). France: Neijla Aissa, MD, Corentine Alauzet, MD, Francois Alla, MD, PhD, CHU Catherine Campagnac, RN, Thanh Doco-Lecompte, MD, Christine Selton-Suty, MD (CHU Nancy-Brabois). Jean-Paul Casalta, MD, Pierre-Edouard Fournier, MD, Gilbert Habib, MD, Didier Raoult, MD, PhD, Franck Thuny, MD (Facult? de M?decine de Marseille). Francois Delahaye, MD, PhD, Armelle Delahaye, Francois Vandenesch, MD (Hospital Louis Pradel). Erwan Donal, MD, Pierre Yves Donnio, PhD, Erwan Flecher, MD, PhD, Christian Michelet, MD, PhD, Matthieu Revest, MD, Pierre Tattevin, MD, PhD (Pontchaillou University). Florent Chevalier, MD, Antoine Jeu, MD, Jean Paul R?madi, MD, Dan Rusinaru, MD, Christophe Tribouilloy, MD, PhD (South Hospital Amiens). Yvette Bernard, MD, Catherine Chirouze, MD, Bruno Hoen, MD, PhD, Joel Leroy, MD, Patrick Plesiat, MD (University Medical Center of Besan?on). Germany: Christoph Naber, MD, PhD, Carl Neuerburg (Universitaetskliniken Bergmannsheil Bochum). Bahram Mazaheri, PhD, Christoph Naber, MD, PhD, Carl Neuerburg (University Essen). Greece: Sophia Athanasia, Ioannis Deliolanis, Helen Giamarellou, MD, PhD, Tsaganos Thomas, MD Efthymia Giannitsioti, MD (Attikon University General Hospital). Elena Mylona MD, Olga Paniara MD, PhD, Konstantinos Papanicolaou, MD, John Pyros MD, Athanasios Skoutelis MD, PhD (Evangelismos General Hospital of Athens). Elena Mylona, MD, Olga Paniara, MD, PhD, Konstantinos Papanikolaou, MD, John Pyros, MD Athanasios Skoutelis, MD, PhD (Evangelismos General Hospital of Athens) India: Gautam Sharma, MD (All India Institute of Medical Sciences). Johnson Francis, MD, DM, Lathi Nair, MD, DM Vinod Thomas, MD, DM, Krishnan Venugopal, MD, DM (Medical College Calicut). Ireland: Margaret M. Hannan, MB, BCh BAO, MSc, John P. Hurley, MB, BCh (Mater Hospitals). Israel: Amos Cahan, MD, Dan Gilon, MD, Sarah Israel, MD, Maya Korem, MD, Jacob Strahilevitz, MD (Hadassah-Hebrew University). Ethan Rubinstein, MD, LL.B, Jacob Strahilevitz, MD (Tel Aviv University School of Medicine). Italy: Emanuele Durante-Mangoni, MD, PhD, Irene Mattucci, MD, Daniela Pinto, MD, Federica Agrusta, MD, Alessandra Senese, MD, Enrico Ragone, MD, PhD, Riccardo Utili, MD, PhD (II Universit? di Napoli). Enrico Cecchi, MD, Francesco De Rosa, MD, Davide Forno, MD, Massimo Imazio, MD, Rita Trinchero, MD (Maria Vittoria Hospital). Paolo Grossi, MD, PhD, Mariangela Lattanzio, MD, Antonio Toniolo, MD (Ospedale di Circolo Varese). Antonio Goglio, MD, Annibale Raglio, MD, DTM&H, Veronica Ravasio, MD, Marco Rizzi, MD, Fredy Suter, MD (Ospedali Riuniti di Bergamo). Giampiero Carosi, MD, Silvia Magri, MD, Liana Signorini, MD (Spedali Civili ? Universit? di Brescia). Lebanon: Zeina Kanafani, MD, MS, Souha S.Kanj, MD, Ahmad Sharif-Yakan, M.D (American University of Beirut Medical Center). Malaysia: Imran Abidin, MD (University of Malaya Medical Center). Syahidah Syed Tamin, MD (National Heart Institute) Mexico: Eduardo Rivera Mart?nez, MD, Gabriel Israel Soto Nieto, MD (Instituto Nacional de Cardiolog?a Ignacio Ch?vez). Netherlands: Jan T.M. van der Meer, MD, PhD (University of Amsterdam). New Zealand: Stephen Chambers, MD, MSc (University of Otago), David Holland, MB, ChB, PhD (Middlemore Hospital), Arthur Morris, MD (Diagnostic Medlab), Nigel Raymond, MB, ChB (Wellington Hospital), Kerry Read, MB, ChB (North Shore Hospital). David R. Murdoch, MD, MSc, DTM&H (University of Otago). Romania: Stefan Dragulescu, MD, PhD, Adina Ionac, MD, PhD, Cristian Mornos, MD (Victor Babes University of Medicine and Pharmacy). Russia: O.M. Butkevich, PhD (Learning-Scientific Centre of Medical Centre of Russian Presidential Affairs Government Medical Centre of Russian). Natalia Chipigina, PhD, Ozerecky Kirill, MD, Kulichenko Vadim, Tatiana Vinogradova, MD, PhD (Russian Medical State University) Saudi Arabia: Jameela Edathodu, MBBS, Magid Halim, MBBS (King Faisal Specialist Hospital & Research Center). Singapore: Yee-Yun Liew, Ru-San Tan, MBBS (National Heart Centre). Slovenia: Tatjana Lejko-Zupanc, MD, PhD, Mateja Logar, MD, PhD, Manica Mueller-Premru, MD, PhD (Medical Center Ljublijana). South Africa: Patrick Commerford, MD, Anita Commerford, MD, Eduan Deetlefs, MD, Cass Hansa, MD, Mpiko Ntsekhe, MD (University of Cape Town and Groote Schuur Hospital). Spain: Manuel Almela, MD, Yolanda Armero, MD, Manuel Azqueta, MD, Ximena Casta?eda, MD, Carlos Cervera, MD, PhD, MD, PhD, Carlos Falces, MD, PhD, Cristina Garcia-de-la-Maria, PhD, Guillermina Fita, MD, Jose M. Gatell, MD, PhD, Magda Heras MD, PhD Jaime Llopis, MD, PhD, Francesc Marco, MD, PhD, Carlos A. Mestres, MD, PhD, Jos? M. Mir?, MD, PhD, Asuncion Moreno, MD, PhD, Salvador Ninot, MD, Carlos Par?, MD, PhD, Juan M. Pericas, MD, Jose Ramirez, MD, PhD, Irene Rovira, MD, Marta Sitges, MD, PhD (Hospital Clinic?IDIBAPS, University of Barcelona, Barcelona, Spain). University of Barcelona, Barcelona, Spain). Ignasi Anguera, MD, PhD, Bernat Font, MD, Joan Raimon Guma, MD (Hospit?l de Sabadell). Javier Bermejo, Emilio Bouza, MD, PhD, Miguel Angel Garcia Fern?ndez, MD, Victor Gonzalez-Ramallo, MD, Mercedes Mar?n, MD, Patricia Mu?oz, MD, PhD, Miguel Pedromingo, MD, Jorge Roda, Marta Rodr?guez-Cr?ixems, MD, PhD, Jorge Solis, MD (Hospital General Universitario Gregorio Mara??n). Benito Almirante, MD, Nuria Fernandez-Hidalgo, MD, Pilar Tornos, MD (Hospital Universitari Vall d?Hebron). Ar?stides de Alarc?n, Ricardo Parra (Hospital Universitario Virgen del Roc?o). Sweden: Eric Alestig, MD, Magnus Johansson, MD, PhD, Lars Olaison, MD, PhD, Ulrika Snygg-Martin, MD (Sahlgrenska Universitetssjukhuset/ ?stra). Thailand: Orathai Pachirat, MD, Pimchitra Pachirat, MD, Burabha Pussadhamma, MD, Vichai Senthong, MD (Khon Kaen University). United Kingdom: Anna Casey, MBBS, Tom Elliott, PhD, DSc, Peter Lambert, BSc, PhD, DSc, Richard Watkin, MBBS (Queen Elizabeth Hospital). Christina Eyton, John L. Klein, MD (St. Thomas? Hospital). United States of America: Suzanne Bradley, MD, Carol Kauffman, MD (Ann Arbor VA Medical Center). Roger Bedimo, MD, MS (Dallas VA Medical Center). Vivian H. Chu, MD, MHS, G. Ralph Corey, MD, Anna Lisa Crowley, MD, MHS, Pamela Douglas, MD, Laura Drew, RN, BSN, Vance G. Fowler, MD, MHS, Thomas Holland, MD, Tahaniyat Lalani, MBBS, MHS, Daniel Mudrick, MD, Zaniab Samad, MD, MHS, Daniel Sexton, MD, Martin Stryjewski, MD, MHS, Andrew Wang, MD, Christopher W. Woods, MD, MPH (Duke University Medical Center). Stamatios Lerakis, MD (Emory University). Robert Cantey, MD, Lisa Steed, PhD, Dannah Wray, MD, MHS (Medical University of South Carolina). Stuart A. Dickerman, MD (New York University Medical Center). Hector Bonilla, MD, Joseph DiPersio, MD, PhD, Sara-Jane Salstrom, RN (Summa Health System). John Baddley, MD, Mukesh Patel, MD (University of Alabama at Birmingham). Gail Peterson, MD, Amy Stancoven, MD (UT-Southwestern Medical Center). Donald Levine, MD, Jonathan Riddle, Michael Rybak, PharmD, MPH (Wayne State University). C.L. receives a grant from FAPERJ (grant #202.782/2015), Rio de Janeiro, Brazil, to support her research in endocarditis. J.M.M. received a research grant from the Institut d?Investigacions Biom?diques August Pi i Sunyer (IDIBAPS), Barcelona, Spain during 2017?2019.
C.L. receives a grant from FAPERJ (grant #202.782/2015), Rio de Janeiro, Brazil, to support her research in endocarditis. J.M.M. received a research grant from the Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain during 2017–2019.
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019.
- Infective endocarditis
- Vegetation size