Early Surgery May Benefit Some With Heart Infection

But doctors say findings only apply to a certain few

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Wednesday, June 27, 2012

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WEDNESDAY, June 27 (HealthDay News) -- People with an advanced form of a heart infection called endocarditis may do better if they undergo early surgery than if they are treated with antibiotics initially, a new study suggests.
Infective or bacterial endocarditis occurs when bacteria settles in the heart lining or heart valve. In advanced cases, the abnormal bacterial growth, often called vegetation, can be large enough to break off and travel elsewhere in the body, such as to the brain, where it may cause a stroke. Advanced infective endocarditis can also damage the heart valve.
People with existing heart disease or heart-valve problems are most likely to develop endocarditis.
In a new study published June 28 in the New England Journal of Medicine, researchers evaluated close to 80 people, average age 47, with advanced infective endocarditis.
Of these, 37 had early surgery within 48 hours of their diagnosis, and 39 received conventional therapy with antibiotics while they were monitored to see if the infection abated. Thirty people placed in the conventional treatment group eventually had surgery.
Early surgery reduced the risk of developing an embolism (or clot) and did not increase the risk of in-hospital death, the study showed.
After six months, the rate of adverse events, including death, repeat hospitalization for congestive heart failure or a recurrence of endocarditis, was 3 percent in the early-surgery group versus 28 percent in the conventionally treated patients.
"Early surgery can be the preferred option to further improve clinical outcomes of infective endocarditis, which is associated with considerable morbidity and mortality," said study author Dr. Duk-Hyun Kang, a cardiologist at University of Ulsan College of Medicine in Seoul, South Korea.
"If a patient with infective endocarditis has large vegetations and severe valve disease, we would advise them to request early referral to medical centers with adequate experience and resources for early surgery," Kang said.
Surgery for infective endocarditis aims to remove all infected tissue, repair the heart tissue and repair or replace the affected valve.
Others experts said only certain patients would warrant early surgery.
The new study "showed that patients with the combination of large vegetations and valve dysfunction, even if they are stable and not in heart failure, have a high risk of suffering serious embolic events or to progress to heart failure with need for emergency surgery and that early surgery prevented these complications," said Dr. Gosta Pettersson, co-author of an accompanying journal editorial and vice chair of thoracic and cardiovascular surgery at the Cleveland Clinic in Ohio.
Surgery does have its share of risks, however. "Historically, surgery for infective endocarditis was high-risk surgery, and the risk of recurrent infection on the replacement valve was also high," he said.
"Today, several publications have demonstrated that the added risk of operating on a patient with active infection has been more or less neutralized," Pettersson added.
Surgeons have become adept at removing all infected tissue and foreign material and determining how best to reconstruct the heart, he explained. "Taking care of this patient is a team work with close collaboration between infectious disease specialists, cardiologists and cardiac surgeons," he said. Importantly, he noted, "surgery is a complement to antibiotics not an alternative."
Not everyone with infective endocarditis should have surgery, Pettersson said. For example, the stable patient with small vegetations, preserved valve function and growth of bacteria sensitive to antibiotics does not need surgery. Severely ill patients who are unlikely to survive an operation or those who have irreversible brain damage from embolism would not be surgical candidates either, he pointed out.
Dr. Stephen Green, chief of cardiology at North Shore University Hospital in Manhasset, N.Y., said that the new findings only apply to a select few. "Patients in the study had very large vegetation and severe valve pathology," Green said. "These tend to be the worst of the worst."
Most people with infective endocarditis are treated with antibiotics. "We reserve surgery for people whose infections don't resolve, have fever or bacteria in the bloodstream or whose valves get destroyed," Green noted.
"Many people with milder forms can be treated with antibiotics and monitored long term to see if they need surgery," he added. This study suggests that "if you get a really bad clump of stuff on a valve, even if it's antibiotic-sensitive, maybe we should go to surgery earlier."

SOURCES: Duk-Hyun Kang, M.D., cardiologist, University of Ulsan, Seoul, South Korea; Gosta Pettersson, M.D., Ph.D., vice chair, thoracic and cardiovascular surgery, and surgical director of lung transplantation, Cleveland Clinic, Ohio; Stephen Green, M.D., chief of cardiology, North Shore University Hospital, Manhasset, N.Y.; June 28, 2012, New England Journal of Medicine

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