Trends in surgical management of infective endocarditis: 15-year experience from a statewide quality collaborative

A. C. Topcu¹, P. F. Theurer², C. He³, M. J. Clark⁴, J. P. Hecht⁵, D. Apostolou⁶, A. Vivacqua⁷, C. L. Willekes⁸, A. L. Pruitt⁹, R. L.. Prager³, F. D.. Pagani^3
1Kosuyolu High Specialization Education and Research Hospital, Ann Arobr, Michigan ²Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, Michigan ³University of Michigan, Ann Arbor, Michigan ⁴Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Pinckney, Michigan ⁵St. Joseph Mercy Ann Arbor, Saline, Michigan ⁶Henry Ford Hospital, Detroit, Michigan ⁷Corewell Health Beaumont Hospital, Royal Oak, Michigan ⁸Spectrum Health, Grand Rapids, Michigan ⁹Michigan Heart & Vascular Institute - CT Surgeons of Ann Arbor, Ypsilanti, Michigan

Purpose: Over the past two decades, there has been an increase in endocarditis-related hospitalizations in the U.S. The objectives of this study were to assess trends in patient characteristics undergoing operation for the indication of infective endocarditis (IE), types of cardiac surgical procedures undertaken, and outcomes following operation.

Methods: Adult patients undergoing open valvular operations for the treatment of IE between January 2008 and June 2022 were retrospectively identified from a statewide quality collaborative database. Transcatheter valvular procedures were excluded. Endocarditis occurring in patients with a history of congenital heart procedures, cardiac implantable electronic devices, heart failure devices, chronic hemodialysis, or immunosuppression was defined as healthcare-associated endocarditis (HAE). Patients were classified into six different categories of surgical complexity (Table). The primary outcome was operative mortality defined as death within 30 days or in-hospital. Secondary outcomes included postoperative stroke, renal failure, prolonged ventilation, sepsis, need for permanent pacemaker implantation, and readmission within 30 days of discharge. All study endpoints were defined according to The Society of Thoracic Surgeons definitions. Pearson’s chi-squared test was used to assess the difference in rates across years. Cochran-Armitage trend test was used to analyze underlying trends across years.

Results: A total of 55,255 valvular operations were performed during the study period. The incidence of valvular operations performed for IE increased from 3.79% in 2008 to 8.9% in 2022 (p <.001) with mortality rates decreasing from 13.57% in 2008 to 8.97% in 2022 (p=.40) (Figure). There was no significant trend in the incidence of HAE (p=.44). The incidence of patients with a history of illicit drug use within 30 days of surgery significantly decreased after 2014 (p=.005). The incidence of surgery for prosthetic valve endocarditis (PVE) did not change over the study period (23.57% in 2008 and 28.21% in 2022, p=.27). Of the surgical cases to address native valve endocarditis, the incidence of right-sided valvular procedures significantly increased (p=.006), surgical operations on the aortic valve without concomitant aortic root procedure significantly decreased (p=.003), and surgical operations involving the aortic root significantly increased from 2008 to 2022 (p <.001). Patients undergoing aortic root procedures experienced the highest mortality, followed by patients undergoing operation for PVE and patients with endocarditis requiring combined aortic and mitral valve operation (16.99%, 11.52% and 10.00%, respectively). Major morbidity was common amongst the different operations (Table).

Conclusion: Between 2008 and 2022, cardiac surgical operations for endocarditis increased along with increasing complexity of operation but without significant change in operative mortality. Valvular operations for IE are increasing and are associated with major morbidity and mortality, and increasing surgical complexity.

Identify the source of the funding for this research project: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Support for MSTCVS-QC is provided by Blue Cross and Blue Shield of Michigan and Blue Care Network as part of the BCBSM Value Partnerships program. Although Blue Cross Blue Shield of Michigan and MSTCSV-QC work collaboratively, the opinions, beliefs and viewpoints expressed by the authors do not necessarily reflect the opinions, beliefs, and viewpoints of BCBSM or any of its employees.