1. Early Surgery versus Conventional Treatment for Infective Endocarditis
N Engl J Med 2012;366:
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.
R3 Kim Se-yun/ prof Ha Sang-jin

2. considerable risk of death and morbidity.
BACKGROUND
considerable risk of death and morbidity.
Infectious
Endocarditis
Medical treatment : IV antibiotics
Surgical treatment : excision of infected tissue & valve repair
2006 American College of Cardiology–American Heart Association (ACC–AHA) guidelines
recommend early surgery as a class IIa indication only
in patients with recurrent emboli and persistent vegetation
revised 2009 European Society of Cardiology guidelines
recommend early surgery as a class IIb indication in patients with isolated, very large vegetations (>15 mm in diameter)

3. BACKGROUND
No randomized trial has been conducted to clarify the indications for surgery and the timing of it that would associated with favorable outcomes
The Early Surgery versus Conventional Treatment in Infective Endocarditis (EASE) trial
to compare the clinical outcomes of early surgery with those of a conventional-treatment strategy
based on current guidelines for patients with left-sided infective endocarditis and a high risk of embolism.

4. METHODS STUDY DESIGN prospective, randomized trial
From September 2006 through March 2011
infective endocarditis : both early surgery and conventional treatment at two medical centers in Korea.
enrolled at the Asan Medical Center (71 patients) and Seoul National University Hospital (5) in Korea

5. METHODS PATIENT SELECTION
18 years of age or older, with left-sided, native-valve infective endocarditis and a high risk of embolism
Blood cultures and transthoracic echocardiography within 24 hours after hospitalization
Diagnosis : the modified Duke criteria
severe mitral valve or aortic valve disease
and vegetation with a diameter greater than 10 mm
Exclusion criteria
moderate-to-severe congestive heart failure
heart block, annular or aortic abscess, destructive penetrating lesions requiring urgent surgery, or fungal endocarditis
age of more than 80 years, coexisting major embolic stroke with a risk of hemorrhagic transformation at the time of diagnosis, and a serious coexisting condition (e.g., cancer)

6. METHODS STUDY PROCEDURES
Evaluation at baseline data
demographic characteristics, predisposing heart disease, manifestations of infective endocarditis, results of blood cultures, use of antibiotic therapy, results of echocardiography, results of radiologic imaging studies, and operative risk
At baseline : transesophageal echocardiography and computed tomography of the brain and abdomen ( using contrast)
early-surgery group :surgery within 48 hours after randomization
conventional-treatment group : according to the AHA guidelines
During followed hospitalization
; at 4 weeks, 6 weeks, 3 months, 6 months, and 1 year; and at 6-month intervals thereafter until September 2011.

7. METHODS STUDY END POINTS primary end point secondary end points
: a composite of inhospital death or clinical embolic events that occurred within 6 weeks after randomization
secondary end points
: at 6 months of follow-up,
- death from any cause, embolic events,
recurrence of infective endocarditis
repeat hospitalization due to congestive heart failure.

8. METHODS STATISTICAL ANALYSIS
the Mann–Whitney U test for continuous variables
Fisher’s exact test for categorical variables
Cox proportional-hazards regression analyses for the outcomes
Kaplan–Meier method, log-rank test
P value of 0.05 was considered to indicate statistical significance.

9. Figure 1. Study Enrollment.

10. RESULTS CHARACTERISTICS OF THE PATIENTS
Table 1. Clinical and Echocardiographic Characteristics of the Patients
at Baseline, According to Treatment Group.

11. RESULTS
Table 2. Characteristics of Antibiotic Therapy, According to Treatment Group.

12. RESULTS SURGICAL PROCEDURES
All patients in the early-surgery group underwent valve surgery within 48 hours after randomization
the median time between randomization and surgery : 24 hours
MV repair : 8 patients
22 patients
;mitral valve involve
MV replacement
( mechanical valve)
: 14 patients
early-surgery group
: 37 patients
AV replacement
(mechanical valve)
: 14 patients
15 patients
; aortic valve
aortic & mitral valve
MV replacement
(biologic prosthesis)
: 1 patients

13. RESULTS SURGICAL PROCEDURES
77%
( 30pt)
underwent surgery
during the initial hospitalization (27patients)
Or during follow-up(3patients)
conventional-treatment group
: 39 patients
MV repair : 11 patients
MV replacement : 6 patients
MV repair + AV replacement : 2 patients
AV replacement : 11 patients

14. RESULTS SURGICAL PROCEDURES
77%
( 30pt)
underwent surgery
during the initial hospitalization (27patients)
Or during follow-up(3patients)
conventional-treatment group
: 39 patients
urgent surgery ( 8 patients)
:, 6.5 days after randomization( mean time)
TIMING
Elective surgery ( 22 patients)
: more than 2 weeks after randomization

15. RESULTS PRIMARY & SECONDARY END POINT
Table 3. Clinical End Points.

16. RESULTS
Figure 2. Kaplan–Meier Curves for the Cumulative Probabilities of Death
and of the Composite End Point at 6 Months, According to Treatment Group..

17. CONCLUSION 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.