Clinical challenges and objectives of the surgical management of infectious endocarditis
Infective endocarditis (IE) remains a complex pathology in cardiac surgery, characterized by severe morbidity and constant therapeutic challenges. Despite the evolution of surgical techniques, the management of patients requiring surgical intervention necessitates a detailed understanding of clinical profiles and variables influencing the immediate postoperative prognosis.
This retrospective single-center study analyzes data from 709 patients surgically managed at Peking Union Medical College Hospital between May 2012 and June 2024. The primary objective is to detail clinical characteristics, pathogen distribution, and short-term outcomes to identify determinants of hospital survival.
The authors explore the hypothesis that specific preoperative factors, such as NYHA functional status, neurological complications, and the nature of the infectious agent, condition the clinical outcome. The analysis aims to demonstrate how rigorous control of surgical timing and optimization of perioperative management can influence the trajectory of patients suffering from left-sided or right-sided IE.
Study design and population
This retrospective single-center study analyzed data from 709 consecutive patients diagnosed with infective endocarditis (IE) and surgically treated within the cardiac surgery department of Peking Union Medical College Hospital between May 2012 and June 2024. The cohort had a median age of 48 years (IQR: 35-58) with a male predominance (68.0%).
Evaluation parameters and protocols
Researchers systematically documented the following variables for each patient:
- Clinical characteristics: Comorbidities, predisposing factors for IE and NYHA (New York Heart Association) functional score.
- Microbiological data: Identification of pathogens (predominance of Streptococcus at 43.2% and specific analysis of Staphylococcus aureus).
- Surgical strategies: Type of intervention (aortic valve replacement in 95.3% of cases or mitral repair in 55.4% of cases) and degree of urgency (11.3% emergency surgeries).
- Preoperative complications: Heart failure (32.7%), valvular dysfunction (90.1%), neurological complications (24.8%) and infectious pancytopenia.
Statistical analyses
The study used statistical analysis models to identify independent risk factors related to hospital mortality and composite adverse events. Results were expressed as Odds Ratios (OR) with 95% confidence intervals (95% CI). The analysis notably distinguished clinical and microbiological profiles between left-sided heart involvement (85.3% of cases) and right-sided heart involvement.
Clinical profile and microbiological distribution
Of the 709 patients included (median age 48 years; 68.0% male), infective endocarditis (IE) involved left-sided valves in 85.3% of cases. Underlying structural heart disease was identified in 66.4% of subjects, while prosthetic valve endocarditis (PVE) accounted for 8.7% of the cohort. The authors note an increased prevalence of comorbidities in patients with left-sided IE compared to right-sided IE.
Microbiological analysis reveals that Streptococci are the predominant pathogens (43.2%). However, a significant disparity is observed according to location: Staphylococcus aureus is more frequently isolated in right-sided forms of the infection.
Surgical strategies and perioperative management
Initial clinical severity was marked by valvular dysfunction in 90.1% of patients and preoperative heart failure in 32.7%. Neurological complications affected 24.8% of cases before the procedure, and 11.3% of the cohort required emergency surgery.
- Aortic involvement: Valve replacement was the rule for 95.3% of patients.
- Mitral involvement: A conservation strategy was preferred with a valve repair rate of 55.4%.
Mortality and risk factors for unfavorable prognosis
Overall hospital mortality is 3.5%, with a composite adverse event rate of 13.5%. Multivariate analysis identified several independent predictors of mortality and morbidity.
| Endpoint criteria | Independent risk factor | Odds Ratio (OR) [95% CI] |
|---|---|---|
| Hospital mortality | NYHA Class III-IV | 5.24 [2.01–13.71] |
| Regional cerebral infarction | 4.09 [1.34–12.49] | |
| Infectious pancytopenia | 3.32 [1.29–8.51] | |
| Preoperative fever | 2.34 [1.00–5.47] | |
| Composite events | NYHA Class III-IV | 3.07 [1.84–5.10] |
| Unstable vital signs | 2.29 [1.26–4.17] | |
| Infection with S. aureus | 2.15 [1.13–4.11] | |
| History of cardiac surgery | 2.10 [1.12–3.96] | |
| Age (per 10-year bracket) | 1.20 [1.02–1.40] |
These data highlight that advanced heart failure (NYHA III-IV) remains the most determining risk factor for perioperative survival in this surgical cohort.
Analysis of survival determinants and surgical choices
Data from this cohort of 709 patients reveal a marked predominance of left-sided involvement (85.3%) and highlight a microbiological dichotomy: while streptococci remain the majority pathogens (43.2%), Staphylococcus aureus infection emerges as an independent risk factor for composite adverse events (OR=2.15). Clinically, the success of mitral valve repair, reaching 55.4%, demonstrates the technical feasibility of tissue preservation even during the infectious phase, in contrast to aortic involvement where replacement remains almost systematic (95.3%).
The study identifies preoperative heart failure (NYHA III-IV) as the most powerful predictor of mortality (OR=5.24). This result, coupled with the impact of neurological complications (cerebral infarctions, OR=4.09) and infectious pancytopenia, suggests that the systemic and hemodynamic status at the time of clamping often takes precedence over the technical complexity of the surgical procedure alone. The fact that 11.3% of interventions are performed as emergencies reflects aggressive management of decompensations, which is essential to limit hospital mortality.
However, these results originate from a single tertiary center, which may induce recruitment bias towards complex cases or, conversely, towards patients stabilized prior to transfer. Although the study confirms certain standards, it specifies specific risks related to age (increased risk every 10 years) and a history of cardiac surgery, which are essential for preoperative prognostic sorting.
Study summary
Analysis of this cohort of 709 patients demonstrates that rigorous surgical management limits hospital mortality to 3.5%, despite a high prevalence of heart failure (32.7%) and neurological complications (24.8%). The results highlight the critical impact of NYHA stage III-IV (OR 5.24) and S. aureus infection on the vital and functional prognosis of operated patients.
In concrete terms, for the practitioner:
- Optimize operative timing: do not wait for extreme hemodynamic worsening, as the transition to NYHA stage III-IV increases the risk of hospital death fivefold.
- Identify high-risk profiles: the presence of infectious pancytopenia or a preoperative cerebral infarction constitutes a major warning signal for immediate survival.
- Anticipate complexity based on the pathogen: when facing Staphylococcus aureus or a patient with a history of cardiac surgery, the risk of composite adverse events is doubled; intensified postoperative monitoring is imperative.
Technical lexicon of the study
Infective endocarditis (IE): Microbial infection of the endocardium, primarily affecting the heart valves (85.3% of left valves in this cohort) and potentially leading to severe tissue destruction.
NYHA (New York Heart Association) Class: Functional classification system for heart failure. Stages III and IV, identified here as major risk factors, correspond to a marked limitation or total inability to perform physical exertion without discomfort.
Infectious pancytopenia: Simultaneous decrease in the three blood cell lines (erythrocytes, leukocytes, and thrombocytes) resulting from systemic sepsis, correlated in this study with an increased risk of hospital mortality.
Prosthetic Valve Endocarditis (PVE): A specific form of IE affecting a previously implanted artificial heart valve, representing 8.7% of patients in this surgical series.
Regional cerebral infarction: Preoperative neurological complication characterized by localized cerebral ischemia, often of embolic origin, identified as an independent predictive factor for postoperative death.
Valvular dysfunction: Mechanical alteration of valve function (stenosis or regurgitation) induced by infection, observed in 90.1% of subjects included before oral surgery.
Composite adverse events: A clinical evaluation criterion grouping several negative outcomes (including mortality and major complications) used to analyze the overall short-term prognosis.
Source
- Original title: Analysis of Surgical Treatment Outcomes in 709 Cases of Infective Endocarditis
- Authors: Chaoji Zhang, WU Zining, Liu Xingrong, Ma Guotao, Shangdong Xu, Liu jianzhou, YANG Sheng, ZHAO Yanxue, LIU Xinpei, Wang Xiaocui, MA Xiaojun, FANG Ligang, YU Chunhua, HE Huaiwu, MIAO Qi, ZHENG Jun
- Publication: DOAJ (DOAJ: Directory of Open Access Journals) - 2025-09-01
- DOI: https://doi.org/10.12290/xhyxzz.2024-0916
Information intended for healthcare professionals. This content may contain errors or truncated summaries. We recommend always verifying with the original source article. Delynov disclaims all responsibility for the use of this information. This document is not intended for patients or the general public.