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Original research
Impact of cardiac surgery on left-sided infective endocarditis with intermediate-length vegetations
  1. Valentina Scheggi1,
  2. Yohann Bohbot2,3,
  3. Christophe Tribouilloy2,3,
  4. Faouzi Trojette2,
  5. Chloé Di Lena4,
  6. Mary Philip5,
  7. Sandrine Hubert6,
  8. Silvia Menale7,
  9. Nicola Zoppetti8,
  10. Stefano Del Pace7,
  11. Pier Luigi Stefàno9,
  12. Gilbert Habib10,
  13. Niccolò Marchionni11
  1. 1Cardiovascular Medicine, Careggi University Hospital, Florence, Italy
  2. 2Cardiology, Amiens University Hospital, Amiens, France
  3. 3UR UPJV 7517, Jules Verne University of Picardie, Amiens, France
  4. 4Amiens University Hospital, Amiens, France
  5. 5Cardiology, Marseille University Hospital, Marseille, France
  6. 6Cardiology, Aix-Marseille University, Marseille, France
  7. 7Cardiology, Careggi University Hospital, Florence, Italy
  8. 8Istituto di Fisica Applicata "Nello Carrara", National Research Council, Sesto Fiorentino, Italy
  9. 9Cardiosurgery, Careggi University Hospital, Florence, Italy
  10. 10Cardiologie, Hospital La Timone, Insuffisance cardiaque et valvulopathie, Marseille, France
  11. 11Research Unit of Medicine of Aging, Department of Clinical and Experimental Medicine, University of Florence and Careggi Hospital, Florence, Italy
  1. Correspondence to Dr Valentina Scheggi, Cardiovascular Medicine, Careggi University Hospital, Florence, 50134, Italy; scheggiv{at}


Objective The best strategy to manage patients with left-sided infective endocarditis (IE) and intermediate-length vegetations (10–15 mm) remains uncertain. We aimed to evaluate the role of surgery in patients with intermediate-length vegetations and no other European Society of Cardiology guidelines-approved surgical indication.

Methods We retrospectively enrolled 638 consecutive patients admitted to three academic centres (Amiens, Marseille and Florence University Hospitals) between 2012 and 2022 for left-sided definite IE (native or prosthetic) with intermediate-length vegetations (10–15 mm). We compared four clinical groups: medically (n=50) or surgically (n=345) treated complicated IE, medically (n=194) or surgically (n=49) treated uncomplicated IE.

Results Mean age was 67±14 years. Women were 182 (28.6%). The rate of embolic events on admission was 40% in medically treated and 61% in surgically treated complicated IE, 31% in medically treated and 26% in surgically treated uncomplicated IE. The analysis of all-cause mortality showed the lowest 5-year survival rate for medically treated complicated IE (53.7%). We found a similar 5-year survival rate for surgically treated complicated IE (71.4%) and medically treated uncomplicated IE (68.4%). The highest 5-year survival rate was observed in surgically treated uncomplicated IE group (82.4%, log-rank p<0.001). The analysis of the propensity score-matched cohort estimated an HR of 0.23 for uncomplicated IE treated surgically compared with medical therapy (p=0.005, 95% CI: 0.079 to 0.656).

Conclusions Our results suggest that surgery is associated with lower all-cause mortality than medical therapy in patients with uncomplicated left-sided IE with intermediate-length vegetations even in the absence of other guideline-based indications.

  • Endocarditis
  • General Surgery

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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  • Contributors VS projected the study and is the guarantor. VS, YB and CT analysed and interpreted the data and wrote the manuscript. FT, CDL, MP, SH and SM collected the data for analysis and contributed to writing the manuscript. NM revised the manuscript. NZ carried out the statistical analysis. PLS, GH and SDP revised the final version of the manuscript. All authors read and approved the final manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.