- A study compared early surgery versus conventional treatment in 76 patients with infective endocarditis of native heart valves - Patients were randomly assigned to early surgery within 48 hours or conventional treatment per guidelines - The primary endpoint was in-hospital death or embolic events within 6 weeks - Early surgery significantly reduced the risk of death or embolism compared to conventional treatment at 6 months by effectively decreasing embolic risk

1. INTERN TALKS
Sherrie Khadanga MD

2. Case presentation
 A 52-year-old woman presents with a 1-week
history of fever, chills, fatigue, and pain in her
L.leg.
 PMH: hypothyroidism
 Med: synthroid, Motrin PRN
 Allergies: none
 FH: non-contributory
 Social hx: denies any drug use but smokes
cigarettes and occasionally drinks 1-2 glasses
of wine per week. Works as a pre-school

3.  Vitals: Tmax 39.2ºC, HR111, BP 118/70, RR
16
 Physical exam:
 GEN: NAD, AAOx3
 CV: 2/6 holosytolic murmur best heard at RUSB
 PULM: CTAB
 ABD: NT, ND, +BS
 Extremities: L.ankle-warm and erythematous;
painful on dorsiflexion

4.  Pertinent labs:
 H/H– 11&28 (mild anemia new)
 WBC– 28
 Blood cultures x2
 TEE– 9cm vegetation on mitral valve
Diagnosis: Infective Endocarditis
Clinical question: What is the appropriate
management for a pt with IE who is
relatively stable with a moderate size

5. Original Article
Early Surgery versus Conventional Treatment for
Infective Endocarditis
Duk-Hyun Kang, M.D., Ph.D., Yong-Jin Kim, M.D., Ph.D., Sung-Han Kim, M.D., Ph.D.,
Byung Joo Sun, M.D., Dae-Hee Kim, M.D., Ph.D., Sung-Cheol Yun, Ph.D., Jong-Min
Song, M.D., Ph.D., Suk Jung Choo, M.D., Ph.D., Cheol-Hyun Chung, M.D., Ph.D., Jae-
Kwan Song, M.D., Ph.D., Jae-Won Lee, M.D., Ph.D., and Dae-Won Sohn, M.D., Ph.D.
N Engl J Med
Volume 366(26):2466-2473
June 28, 2012

6. Background
 Early surgery is indicated for patients with
infective endocarditis and CHF but indications
for surgical intervention to prevent systemic
embolism has not been clearly defined
 ACC-AHA guidelines (2006) recommend early
surgery as a class IIa indication only in
patients with recurrent emboli and persistent
vegetation
 European Society of Cardiology guidelines
(2009) recommend early surgery as a class IIb
indication in patients with isolated lg
vegetation (>15mm)

7. Indications for and Timing of Surgery in Patients
with Left-Sided, Native-Valve Infective
Endocarditis

8. Purpose of Study
 Timing and indications for surgical intervention
to prevent systemic embolisms remain
controversial
 The EASE trial was conducted to compare
clinical outcomes of early surgery and
conventional treatment in patients with
infective endocarditis of the native valves
 The major hypothesis was that early surgery
would decrease the rate of death or embolic
events as compared with conventional
treatment

10.  Patients were randomly assigned in a 1:1 ratio to
the early surgery group or conventional treatment
 Treatment assignments were computer generated
and stratified according to the involved valve
 Those in the early surgery group underwent
surgery 48 hours after randomization
 Patients assigned to conventional treatment group
were treated according to AHA guidelines and
surgery was performed only if complications
requiring urgent surgery developed during medical
treatment or if symptoms persisted after
completion of antibiotic therapy

11. Clinical and Echocardiographic Characteristics of the
Patients at Baseline, According to Treatment Group.
-Study conducted from Sep ‘06- March ‘11
-total of 76 patients enrolled
-mean age- 47 years old
-67% male
-mitral valve involved in 45 patients
-aortic valve involved in 22 patients
-9 patients had involvement of both valves
-median diameter of vegetation-12mm
-most common pathogen in both groups:
-Viridans 30%
-S.aureus 11%

12. Characteristics of Antibiotic Therapy, According to
Treatment Group.

13. Statistical Analysis
 Estimated that a sample of 74 patients would
provide 80% power to detect a significant
difference with respect to the primary end
point
 Analyses were performed with intention to
treat
 Since randomization was stratified according
to involved valve, stratified Cox proportional
hazards progression analyses were done for
the outcomes

14. Clinical End Points
Primary End Point:
Composite of in-hospital death or clinical
embolic events that occurred within 6
weeks after randomization
An embolic event was defined as acute
onset of symptoms or signs of embolism or
occurrence of new lesions
Secondary end points (at 6 months):
-death from any cause
-embolic events
-recurrence of IE
-repeat hospitalization due to dev of CHF

15. Kaplan–Meier Curves for the Cumulative Probabilities of
Death and of the Composite End Point at 6 Months,
According to Treatment Group

16. Discussion
 Systemic embolism which occurs roughly in
1/3 of patients with IE and often involves CNS
(65%), is the second most common cause of
death (after CHF)
 In this study, in hospital and 6 month mortality
in both groups was substantially lower than
that reported previously
 Proportion of patients with poor prognostic factors
were lower compared to other studies
 Moderate to severe CHF, AMS, staph infections

17. Limitations
 Limited in scope– pts excluded were those
with major stroke, IE with prosthetic valve, or
aortic abscess
 Incidence of S.aureus was lower than in
previous studies
 Patients in this study had low operative risk

18. Conclusions
 As compared with conventional treatment,
early surgery in patients with infective
endocarditis and large vegetations significantly
reduced the composite end point of death from
any cause and embolic events by effectively
decreasing the risk of systemic embolism.