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Antibiotics are the standard treatment for native valve infective endocarditis with surgery primarily reserved for patients with heart failure or inadequate response to antibiotic treatment, as recommended by the American College of Cardiology/American Heart Association (ACC/AHA) guidelines (Circulation. 2008 Oct 7;118(15):e523). However, the risk of death can be high even in patients without heart failure due to the risk of systemic embolism, and in these patients, the optimal timing for surgery remains under debate. The EASE randomized trial compared early surgical intervention vs. standard care in 76 patients (mean age 47 years) with left-sided endocarditis, severe valve disease, and vegetation > 10 mm in diameter. The early surgery group had surgery within 48 hours of randomization. The standard care group had treatment based on ACC/AHA guidelines with surgery performed only if urgent complications or symptoms persisted after antibiotic therapy. Patients with major stroke, aortic abscess, or prosthetic valve endocarditis were excluded.
The median time to surgery for the early surgery group was 24 hours from randomization. In the standard care group, 69% (27 patients) had urgent surgery during hospitalization at median 6.5 days after randomization, and 3 patients had elective surgery more than 2 weeks after randomization.
At 6 weeks follow-up, there were no embolic events in the early surgery group compared to a rate of 21% in the standard care group (p = 0.005, NNT 5) (level 1 [likely reliable] evidence). There were no significant differences in in-hospital mortality (3% vs. 3%). There were no additional embolic events in either group at 6 months follow-up. All-cause mortality was 3% vs. 5% (not significant). The endocarditis recurrence rates were similar between groups (0% vs. 3%, not significant) (N Engl J Med 2012 Jun 28;366(26):2466).
For more information, see the Infective endocarditis topic in DynaMed.