Research Of Early Surgical Treatment For Infective Enocarditis

Background and Objective: Infective endocarditis(IE)is one kind of infective disease in cardiac endothelium,with the characteristics of formation of vegetations and destruction of valve tissues,caused by pathogens(bacteria,fungi,etc.)via blood stream.The deterioration of cardiac function is the most frequent clinical performance and the fetal reason.Vegetations,loose and easily to be dropped off,can induce vital embolism or infarction in important organs,like cerebrum.Because of the formation of abscesses and the characteristic of pathogens,infection can be controlled hardly in some patients with IE.According to the reference and clinic report,surgical therapy should be performed in the patients with the characteristic of poor cardiac function,embolisms,infection failed to be treated medically,and malign arrhythmias.In the patients with the characteristics above,the results of surgery is better than that of medical therapy alone.However,the timing of surgery is still debated.In conservative treatment strategy for selective surgical cases,the surgeries usually get performed after 4-6 weeks since the inflammation has been controlled.In recent years,some reports support that early surgical intervention could get better outcome in some IE patients with the characteristics above,before the infection is controlled.Better outcomes have been reported from surgical therapy in most of the articles.Optimal timing for surgery is the focus domain nowadays.Early surgery has been recommended by some articles and even by guidelines in America and Europe.It could reduce mortality and improve heart function of patients with IE.Except of one RCT study,the conclusions are derived from observational studies.The conclusion may be influenced by following factors: hidden group,treatment bias,survivor bias,referral bias,and some other confounding factors.Additionally,the definition of ‘early surgery’ has not been confirmed even yet,and this could be a confounding factor.As a result,it is still controversial in whether early surgical therapy could result in better outcomes.Because of the rare incidences and ethics limitations,Meta-analysis could make efforts in this domain.In the concern of different mortality between NVE and PVE,we focus on the effect of early surgical therapy for the patients with NVE.Meta-analysis has been used in our study to estimate the effect of surgical and early surgical therapy for the patients with NVE.Since 2008,we accepted the advances of reference and some reports,to perform early surgery in certain IE patients.The purpose of this study is to summarize the performances of the new strategy of early surgical treatment.Material and methods: We had retrospectively taken 143 consecutive cases hospitalized with the diagnosis of IE,between 1996.6 and 2011.7.All patients meted the identified Duke strategy.Of them,135 patients(94.4%)were followed via telephone,e-mail,and other ways.They are in the following analysis.Clinical data of all the patients were collected,including patients’ general information,co-existing diseases,clinical manifestations,pathogens,echocardiography findings,treatment during hospitalization and discharge conditions.The patients were divided into 2 groups: Group A(after 2008,early surgery group)and Group B(before 2008,conventional group).Nonparametric rank sum test,chi-square test,and t test were used to make the comparison between different groups.Multivariate Logistic regression method was used to confirm the independent prodictors.Kaplan–Meier survival test was used to show the follow-up survival condition of patients.Pub Med and EMBASE databases were searched for English and Chinese language.The articles published during January,1990 to June,2015,including clinical trials which compared early surgery and conventional medicine for active native infective endocarditis.The qualities of the data were assessed by two independent researchers.The quality of the trials included in this study was assessed by each researcher according to the Cochrane Handbook for Systematic Reviews of Interventions,version 5.1.0.A meta-analysis was carried out with Rev Man 5.3 software on in-hospital mortality,follow-up mortality,IE-related mortality and recurrence of IE.Results: 135 out of 143 patients with IE were followed up and analyzed.Male accounts for 94 cases(69.6%),female 42 cases(30.4%);aged 16-84 years,with the average 46.5±14.8 years;course 21-752 days,with the average 130.8 ±112.0 days.There were 74 cases in group A and 61 cases in group B.70 cases received surgery,65 cases got medical treatment alone.IE related death is 21 cases(15.6%).Thereasons of death were as follow: heart failure in 10 cases,cerebrovascular accidents in 5 cases,heart failure with renal failure in 3 cases,multiple organ failure in 2 cases,and respiratory failure in 1 case.No embolism event happened in either group.Patients in group A had lower mortality(9.4% vs.23.0%,p=0.016),less heart failure rate(5.4% vs.26.2,p<0.001),and higher surgical rate(67.6% vs.32.8%,p<0.001).There was no significant recurrent rate between the two groups.There were more patients in group A getting higher risk.Patients,who died within 1 month after discharge,got a higher proportion of clinical characteristics(p< 0.05),including cerebral embolism,albumin deficiency,moderate to severe heart failure and moderate to severe anemia.After multivariate regression analysis,cerebral embolism was the highest hazardous factor(p=0.034,OR=5.598)for short-term mortality of IE.In meta-analysis research,ten studies were included with 4219 cases.The meta-analysis outcomes indicated that there was significant difference(P<0.05)between two compared groups on in-hospital mortality,follow-up mortality and IE-related mortality,there wasn’t significant difference(P>0.05)on recurrence of IE.Conclusions: 1.Early surgery therapy could reduce mortality rate in patients with IE(NVE).2.Early surgery therapy would not elevate the risk of recurrence of infection in patients with IE(NVE).3.Short-term IE related mortality was associated with cerebral vascular embolism,hypoproteinemia,heart failure,and anemia,among which cerebral embolism was the most hazardous factor.