Risk factors for early and late outcome after surgical treatment of native infective endocarditis.

Cardiac valve replacement was performed on 76 patients with acute or subacute native infective endocarditis. The 30-day mortality/5-year survival (%/% +/- SE) was 18/67 +/- 7, after aortic valve replacement (n = 50), 6/82 +/- 10 in the mitral group (n = 18) and 38/63 +/- 17 after double valve replacement (n = 8): NS/NS. In patients with destruction and/or abscess of the anulus (DESAB), which was commonest in the aortic group, the corresponding figures were 31/48 +/- 10, compared with 10/81 +/- 6 in the other patients (p less than 0.05/less than 0.01). Atrioventricular block and complete bundle branch block were commoner in the former group. When the time from onset of fever to operation was 1-6 months (n = 50), the 5-year survival was 79 +/- 6% compared with 51 +/- 10% (p less than 0.05) when that time was less than 1 month (n = 14) or greater than 6 months (n = 12). Logistic regression analysis showed NYHA class III-IV and DESAB to be independent risk factors in 30-day mortality, which was 3.8% when neither, and 46.2% when both of these factors were present (p less than 0.01). Cox regression analysis identified NYHA class IV (p less than 0.0001), calcified mitral valve or anulus (p = 0.001), DESAB (p = 0.01), male gender (p = 0.02), supraventricular arrhythmia (p = 0.04) and vegetations on the diseased valve (p = 0.05) as independent determinants of overall long-term mortality. Patients with none (n = 6), any one (n = 16), any two (n = 28), any three (n = 20), any four (n = 6) or any five (n = 2) of these risk factors (none had 6) had respective 30-day/5-year survival rates (% +/- SE) of 100/100, 94 +/- 6/94 +/- 6, 89 +/- 6/85 +/- 7, 75 +/- 10/43 +/- 13, 67 +/- 9/17 +/- 15 (at 1 year) and 0/0 (p less than 0.0001). Identification of independent risk factors permitted stratification of the patients into subgroups with prognosis ranging from 100% 5-year survival to 0% 30-day survival. Surgical treatment of native infective endocarditis should be undertaken before cardiac disability is advanced or infective destruction of the anulus, notably of the aortic valve, becomes evident.