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Cardiac surgery added nothing to survival of patients who developed infective endocarditis after transcatheter aortic valve replacement (TAVR) and were getting antibiotics, a German center found from its own experience.

All-cause mortality rates were not statistically different between patients getting both surgery and antibiotics and peers getting just the latter, even after accounting for baseline differences between groups (65% versus 75%, P=0.490), according to a team led by Norman Mangner, MD, of Germany's Heart Center Dresden, Technical University of Dresden.

In fact, cardiac surgery patients were observed to have more complications from their management of the infection (P=0.024), the group reported online in the .

"Hypothetically, this higher complication rate may have outweighed the potential benefit of cankerous tissue removal," the investigators suggested.

Actually associated with mortality, however, were:

• Indication for surgery (HR 6.20, 95% CI 1.80-21.41)
• Severe infective endocarditis, patient reaching sepsis on admission (HR 4.03, 95% CI 1.97-8.24)
• Mitral regurgitation ≥2 (HR 2.91, 95% CI 1.33-6.37)

"Early surgery in patients with native valve endocarditis and severe valve dysfunction or large vegetations reduces the risk of the combined end point of in-hospital death and embolic events," Mangner and colleagues said, noting that the treatment of high-risk TAVR recipients who developed infective endocarditis is "much more uncertain" and data more rare.

In the absence of conclusive evidence for or against cardiac surgery in this setting, the authors advocated an individual decision-making approach with the help of a "heart and endocarditis team."

"We do not currently have enough published data to conclude that surgery is or is not better than medical therapy alone in patients with TAVR-IE," agreed Gilbert Habib, MD, PhD, of La Timone Hospital in Marseille, France, in an .

"For this reason, the decision to operate or not should be individualized for each patient depending on his or her clinical status, operative risk, and comorbidities," Habib continued. "[B]ecause both diagnosis and treatment choice are particularly difficult for patients with suspected TAVR-IE, these patients should be referred to reference centers and any decision should be taken by the endocarditis team."

Habib noted that such teams are becoming more prevalent in European centers.

For the study, 64 consecutive patients who underwent TAVR in 2008-2017 and had infective endocarditis subsequently treated at Heart Center Dresden were included. Participants were required to have echocardiographic evidence of vegetation, abscess, and/ or new dehiscence of the prosthetic or another valve after TAVR.

The 44 individuals who got antibiotics only formed an older group (average age 81.5 versus 77.3 years for surgery recipients, P=0.006), were at higher risk (median Society of Thoracic Surgery score 23.3% versus 17.2%, P=0.029), and more often presented with severe chronic kidney disease (63.4% versus 35.0%, P=0.037).

"The decision by the heart team might be an important bias in this analysis," Mangner's group wrote. "However, typically in such a scenario, younger and 'healthier' patients are sent to surgery, whereas older and 'futile' patients are denied high-risk and invasive procedures."

The study population typically developed endocarditis months after TAVR and had cardiac surgery performed at median 17 days after the diagnosis was confirmed.

It remains unknown what, if any, is the optimal time for surgery, Mangner and colleagues said.

"Pending the results of future studies," Habib concluded, "we should recognize that factors other than surgery mainly influence outcome in patients with TAVR-IE, including comorbidity, frailty, heart failure, renal failure, and, in the current paper, disease characteristics."