Twenty-five year outcomes of patients undergoing valve surgery for infective endocarditis

Objectives — Infective endocarditis is associated with significant morbidity and mortality. Long-term outcome data after surgery are limited. We sought to analyze 25-year outcomes following valve surgery for endocarditis.

Methods — We conducted a retrospective cohort study of patients undergoing valve surgery for infective endocarditis at Toronto General Hospital (1990–2014), linking clinical and administrative data with follow-up until March 2024 (median 14 years). We assessed survival and freedom from major adverse valve-related events (MAVRE), stratified by remote endocarditis and active endocarditis with and without abscess. Cox regression was used to identify predictors of long-term outcomes.

Results — Among 1,095 patients (mean age 53.8±15.4 years, 67.3% male), 511 had remote endocarditis, 447 had active endocarditis without abscess, and 137 had active endocarditis with abscess. Twenty-five-year survival was 39.5% (remote), 30.8% (active without abscess), and 26.0% (active with abscess) (p<0.0001). Freedom from MAVRE 25 years after valve surgery was 22.1%, 15.7%, and 12.6%, respectively (p<0.0001). An important driver of the composite MAVRE was higher permanent pacemaker/ cardioverter-defibrillator implantation in the active group with abscess. Multivariable predictors of late mortality included active infection with abscess, left ventricular dysfunction, vascular disease, diabetes, pulmonary disease, kidney disease, stroke, frailty, and lower neighbourhood income.

Conclusions — Patients undergoing valve surgery for active infective endocarditis with abscesses have worse long-term outcomes compared to those with remote or active endocarditis without abscesses. Infection severity, comorbidities, left ventricular dysfunction, and socioeconomic factors are associated with long-term mortality post IE surgery.