The waiting game in infective endocarditis: consequences of delayed surgery

Introduction

Infective endocarditis (IE) is a severe condition associated with local and systemic complications, such as heart failure, uncontrolled infection, and septic embolization. These complications often necessitate urgent (within 3–5 days) or emergent (within 24 hours) surgical intervention, which can improve first-year survival rates by up to 20%.

Objectives

To characterize a population of patients diagnosed with IE and evaluate the timing of surgical intervention in patients with IE-related complications.

Methods

A retrospective analysis was conducted at a single medical center on patients diagnosed with IE and surgically intervened between January 2020 and December 2023, with a mean follow-up of 19.8±16.8 months. Patients were categorized based on the need for urgent surgery. Data included demographic characteristics, microorganisms, infection sites, vegetation size, and IE-related complications. Additionally, we assessed clinical outcomes, including IE recurrence, re-hospitalization rates, overall mortality, in-hospital mortality, and mortality within the first-year post-diagnosis.

Results

The study included 25 patients (mean age 62 ± 16 years; 76% male). Of these, 20 (80%) had indications for urgent surgery, and 5 (20%) did not. Both groups were largely similar in clinical characteristics, except for a significantly higher prevalence of cardiac devices in the non-urgent group (80% vs 15%, p=0.012). Aortic bioprosthetic valves were more frequently affected in the non-urgent group (33% vs 7%, p=0.029), while mitral valves were predominantly affected in the urgent surgery group (2% vs 0%, p=0.029). The absence of complications was more common in the non-urgent group (60% vs 0%, p<0.001).

Despite a higher trend of complications in the urgent surgery group, no significant differences in overall prevalence were observed. The mean time to surgery for patients with urgent indications was 27±20 days, with no patients undergoing surgery within the critical five-day window recommended by clinical guidelines.

Conclusion

While complications were more frequent in patients requiring urgent surgery, delays in intervention consistently exceeded guideline-recommended timelines, with no surgeries performed within five days. Although limited by the small sample size and single-center design, this study underscores the need for improved protocols to ensure timely surgical intervention, potentially enhancing outcomes for patients with IE-related complications.For image description, please refer to the figure legend and surrounding text.