Adult: Endocarditis
Surgical treatment of infective endocarditis at comprehensive versus primary valve centers

https://doi.org/10.1016/j.jtcvs.2021.09.023Get rights and content

Abstract

Background

A recent expert consensus statement proposed designation of comprehensive and primary valve centers, with a recommendation that comprehensive centers house surgical skill and resources to treat patients with infective endocarditis (IE). We sought to compare outcomes of patients who underwent valve surgery for IE at comprehensive versus primary valve centers within a large health care system.

Methods

We reviewed 513 consecutive patients who underwent IE surgery at 8 hospitals (2 comprehensive and 6 primary valve centers) from 2014 to 2020. Outcomes from comprehensive and primary valve centers were compared after propensity score matching on the basis of patient characteristics, valve involvement, valve type, and IE treatment status. Multivariate logistic regression was used to identify risk factors for operative mortality.

Results

Propensity score matching generated comparable groups with similar mean Society of Thoracic Surgeons/Gaca IE risk scores among comprehensive and primary valve center cohorts. Comprehensive valve centers were more likely to perform the Bentall procedure (60.4% vs 21.7%; P < .01) when aortic root abscess was present and mitral valve repair (50.4% vs 26.3%; P < .01) in cases of mitral valve involvement. Operative mortality was significantly lower at comprehensive valve centers (6.2% vs 13.0%; P = .04), and multivariate logistic regression suggested that surgery at comprehensive valve centers was protective against operative mortality (odds ratio, 0.39; 95% confidence interval, 0.17-0.88; P = .02). Similar findings were present in a sensitivity analysis limited to patients with active IE only.

Conclusions

An increased risk for operative mortality was associated with surgery performed at primary valve centers compared with comprehensive valve centers. Referral or transfer of patients with IE and surgical indications to comprehensive valve centers should be considered.

Graphical abstract

Study summary. A retrospective, propensity-matched cohort study was performed to analyze short- and long-term outcomes of patients who underwent valve surgery for infective endocarditis within a large health care system from 2014 to 2020. Despite facing similar predicted operative risks, patients who underwent surgery at a comprehensive valve center (CVC) had decreased operative mortality compared with patients who underwent surgery at a primary valve center (PVC). CVCs more commonly performed complex valvular surgery including Bentall procedure and mitral valve repair. IV, Intravenous; OR, odds ratio.

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Section snippets

Study Design and End Points

We conducted a retrospective review of adult (age older than 18 years) patients who underwent valve surgery for IE at hospitals within the Baylor Scott & White Healthcare System from July 1, 2014, through September 1, 2020. The Baylor Scott & White Healthcare System is comprised of 50 hospitals in North and Central Texas. Of these, 8 hospitals performed at least 1 valve surgery for IE. For comparisons, the 8 hospitals were designated as CVC or PVC according to the criteria proposed by a recent

Results

A total of 513 patients with IE who underwent valve surgery and otherwise satisfied the inclusion/exclusion criteria were identified. Of these, 388 (75.6%) patients underwent surgery at a CVC, and the remaining 125 (24.4%) patients underwent surgery at a PVC. CVC also performed a higher volume of non-IE-related valve surgery (Figure 1).

Before propensity matching, there were several differences in the baseline characteristics of patients who underwent surgery at CVCs versus PVCs (Table 1). Most

Discussion

Herein, we have reported the short- and long-term outcomes of propensity matched cohorts of patients who underwent valve surgery for IE at hospitals that met criteria for CVC or PVC designation within a single health care system. Our primary findings are the following: (1) patients who underwent valve surgery for IE are at lower risk for operative mortality at hospitals that meet criteria for CVC designation compared with PVCs, (2) CVCs are more likely to perform complex valve interventions

Conclusions

We have shown that a lower risk of operative mortality for patients who underwent valve surgery for IE within our large health care system was associated with surgery performed at hospitals that met criteria for CVC designation. CVCs more commonly performed complex operative interventions including the Bentall procedure and mitral valve repair. In patients with active IE, improvement in short- and long-term survival was associated with surgery performed at CVCs. These findings provide initial

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    • This work was supported by a grant from the Baylor Scott & White Healthcare System Cardiovascular Research Review Committee. J.J.S., J.K.B., M.H., R.B., and E.S. are supported by a philanthropic gift from Satish and Yasmin Gupta.

    ∗

    Baylor Scott & White Surgery for Endocarditis Working Group: Ronald Baxter, MD,c Mohanad Hamandi, MD,a Emily Shih, MD,c Gonzalo Gonzalez-Stawinski, MD,d Charles Roberts, MD,c Robert L. Smith II, MD,b William T. Brinkman, MD,b Katherine B. Harrington, MD,b Kelley A. Hutcheson, MD,b Justin M. Schaffer, MD,b and Timothy J. George, MDb; and cBaylor University Medical Center, Dallas, Tex; and dBaylor Scott & White All Saints Medical Centers, Ft Worth, Tex.

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    © 2021 by The American Association for Thoracic Surgery