A predictive model for early mortality after surgical treatment of heart valve or prosthesis infective endocarditis. The EndoSCORE☆
Introduction
Surgical treatment of heart valve and prosthesis infective endocarditis (IE) is account for 25–50% of cases in active IE and 20–40% in treated IE [1], [2], [3], [4]. The mortality rate is very heterogeneous, ranging from 6 to 36% [5], [6], [7], [8], [9], [10], [11], [12], [13], [14].
The European System for Cardiac Operative Risk Evaluation (Euroscore), either I or II [15], [16], have been developed for risk assessment in general population undergoing cardiac surgery. Recently, these models were demonstrated to underestimate mortality in patients within lower risk strata and to overestimate mortality among patients at higher risk [17], [18], [19]. In a recent study [19], the Euroscore II was applied in a cohort of 149 cases with IE undergoing surgery, demonstrating as Euroscore II underestimates mortality by 5–10% when predicted mortality was higher than 10%.
Some studies have already addressed the issue to provide a specific risk score for early outcome according to pre- and operative data [20], [21], [22], [23]. De Feo et al. [20] compared Euroscore with their specific score in a subset of 252 patients undergoing surgery for IE; Area under curve of their score was significantly higher than Euroscore for the more specific model (0.91 versus 0.84). However, the role of Euroscore in this specific field remains still debated, since other studies showed good discrimination [24], [25].
Given the recent callout to report logistic models for the assessment of risk for surgery in case of valve or prosthesis IE [26], we reviewed the experience of 26 Italian Cardiac Surgery Centers to provide a logistic risk model for predicting early mortality of patients with heart valve and prosthesis IE undergoing surgery.
Section snippets
Study population
From 2000 to 2015, 2715 patients with native valve endocarditis (NVE) or prosthesis valve endocarditis (PVE) were operated on in 26 Italian Cardiac Surgery Centers (Appendix A) with a mean prevalence of 2.0% (1.4%–2.5%) of overall surgical population in the same Centers across the same period. Pre- and Operative characteristics are listed in the Table 1.
Definition of terms and end-points
All the variables collected in the dataset were defined according to Euroscore [15]. The primary end-point was early mortality, defined as
Results
Early mortality was 11.0% (298/2715). The following variables were found to be related to higher early mortality at univariate analysis (Table 1): age classes; female gender; lower left ventricular ejection fraction (LVEF); site of IE; aortic regurgitation; prosthesis involvement, preoperative shock or heart failure, severe pulmonary hypertension, diabetes, chronic obstructive pulmonary disease (COPD), creatinine value equal or higher 2 mg/dl, reoperation, presence of abscess, number of treated
Discussion
The possible reason for discrepancy between Euroscore and more specific scores is very likely due to the low prevalence of IE among cohorts used to develop both versions of Euroscore (1.1% in Euroscore I and 2.2% in Euroscore II). Hence, the contribution of IE related features might have been diluted in the final models. In fact, Euroscore does not sufficiently take into account surgical difficulties due to extent of locally infected tissue (i.e. abscess), sepsis-related disorders (i.e.
Limitations
The main limitation of this study is the retrospective nature so that we were unable to investigate the prognostic role of some variables as the interval time from IE onset and surgery, recurrent embolization, persistent positive cultures. Concerning the timing of surgery, no significant difference was found for active versus treated endocarditis at univariate; however, we are unable to define the exact timing of surgery for any patient.
In conclusion, although these limitations, GIROC provides
References (30)
- et al.
Active native valve endocarditis: determinants of operative death and late mortality
Ann. Thorac. Surg.
(1997) - et al.
Surgery for active culture-positive endocarditis: determinants of early and late outcome
Ann. Thorac. Surg.
(2000) - et al.
Prognostic stratification of patients with left-sided endocarditis determined at admission
Am. J. Med.
(2007) - et al.
Treatment of endocarditis: a decade of experience
Ann. Thorac. Surg.
(2007) - et al.
Valve surgery in active infective endocarditis: a simple score to predict in-hospital prognosis
Int. J. Cardiol.
(2014) Risk scores for endocarditis surgery: callout for reporting logistic models
Int. J. Cardiol.
(2016)- et al.
Management strategies and outcome for prosthetic valve endocarditis
Am. J. Cardiol.
(2013) - et al.
Long term outcome of infective endocarditis in patients who were not drug addicts: a 10 year study
Heart
(2000) - et al.
Contemporary clinical profile and outcome of prosthetic valve endocarditis
JAMA
(2007) - et al.
Clinical presentation, etiology, and outcome of infective endocarditis in the 21st century: the international collaboration on endocarditis-prospective cohort study
Arch. Intern. Med.
(2009)
Mortality from infective endocarditis: clinical predictors of outcome
Heart
Complicated left-sided native valve endocarditis in adults: risk classification for mortality
JAMA
Impact of valve surgery on 6-month mortality in adults with complicated left sided native valve infective endocarditis: a propensity analysis
JAMA
Prosthetic valve endocarditis: who needs surgery? A multicenter study of 104 cases
Heart
In-hospital mortality of infective endocarditis: prognostic factors and evolution over an 8 year period
Scand. J. Infect. Dis.
Cited by (46)
Infective Endocarditis—Update for the Perioperative Clinician
2023, Journal of Cardiothoracic and Vascular AnesthesiaFuture directions in infective endocarditis
2022, Infective Endocarditis: A Multidisciplinary ApproachPrognostic models for mortality after cardiac surgery in patients with infective endocarditis: a systematic review and aggregation of prediction models
2021, Clinical Microbiology and InfectionCitation Excerpt :Participants were recruited between 1980 and 2015 (see Supplementary material, Table S3). Three models were developed to predict any death occurring before discharge or within 30 days of surgery [24,26,30], five models to predict any death occurring before discharge [25,29,31,32], and the remaining three as death within 30 days of surgery [27,28]. The incidence of deaths varied between 8.2% and 29.2% (Table 1).
Infective endocarditis: Time for new diagnostic criteria and management strategies?
2020, Hellenic Journal of CardiologyUsing surgical risk scores in nonsurgically treated infective endocarditis patients
2020, Hellenic Journal of CardiologyCitation Excerpt :The authors of the present study speculated whether commonly used risk scores, structured to predict in-hospital mortality following an operation for IE, could be informative for the medically only treated cohort of patients from an extensive national registry. It is known from the literature [3,7–16] that further validation studies are required to adopt the most promising risk score, from the available ones, regarding the prognostic accuracy of surgical mortality for IE. The task will be even more difficult if similar scores are applied to the solely medically treated IE patients, as it would refer to an heterogeneous group of patients that includes (1) those without a need for surgery, (2) those reluctant to undergo surgical treatment despite the fact that the operation is indicated, and (3) patients with severe comorbidities that make the surgery a futile option.
Effect of lung protective ventilation on perioperative pulmonary infection in elderly patients with mild to moderate COPD under general anesthesia
2020, Journal of Infection and Public Health
- ☆
No potential conflicts exist; No funding was provided.