Early Surgery Beats Conventional Treatment for Endocarditis

Early surgery is better than conventional treatment for patients with infective endocarditis, suggest findings from the EASE trial. “As compared with conventional treatment, early surgery in patients with infective endocarditis and large vegetations significantly reduced the composite endpoint of death from any cause and embolic events by effectively decreasing the risk of systemic embolism,” explain the study authors in the New England Journal of Medicine. “We suggest that early surgery is a valuable therapeutic option to prevent embolism,” they say. The Early Surgery versus Conventional Treatment in Infective Endocarditis (EASE) trail was designed to compare the clinical outcomes of early surgery with those of a conventional treatment strategy that is based on current guidelines for patients with left-sided infective endocarditis and high risk for embolism. The researchers, led by Duk-Hyun Kang from the University of Ulsan in Seoul, South Korea, randomly assigned 76 consecutive patients (mean age 47 years) with left-sided native-valve infective endocarditis, severe valve disease, and large vegetations to receive early surgery (n=37) or conventional treatment (n=39). Patients assigned to the early-surgery group underwent surgery within 48 hours of randomization while patients assigned to the conventional treatment group were treated according to the American Heart Association guidelines. The researchers report that the primary endpoint of in-hospital death or embolic events within the first six weeks after randomization occurred in significantly more patients in the conventional treatment than in the early surgery group (23 vs 9 %). There was no significant difference in all-cause mortality at six months in the conventional treatment and early surgery groups (5 vs 3 %). However, the rate of the composite end point of death from any cause, embolic events, or recurrence of infective endocarditis at six months was 28 % in the conventional treatment group compared with just 3 % in the early surgery group. In an accompanying editorial, Steven Gordon and Gösta Pettersson, from the Cleveland Clinic in Ohio, US said: “The implication of this study for early surgery is profound and raises the bar for the treatment of patients who do not have urgent indications but do have valve dysfunction and vegetations.” “This study underscores the points that infective endocarditis is a dangerous condition and that the benefits of timely surgical intervention in patients with large vegetations and severe valvular dysfunction, event if they do not have congestive heart failure, outweigh the additional risk of surgery in patients with active infection.” They conclude: “Because it is difficult to identify patients who might benefit from early surgery, we would argue that early referral to medical centres with the necessary cardiac surgical experience and resources is warranted for all patients with left-sided, native-valve infective endocarditis who have important valve dysfunction, large vegetations, or invasive disease beyond the cusps or leaflets—not just for those patients with urgent indications.” By David Ramsey