Cardiac surgery timing on the prognosis of patients with infective endocarditis

Cardiac surgery timing on the prognosis of patients with infective endocarditis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Cardiac surgery timing on the prognosis of patients with infective endocarditis Wu Liu, Yongqin Li, Heng Yang, Jingyu Wang, Wanqi Lan, Congcong Li, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6760790/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 23 Dec, 2025 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted 19 You are reading this latest preprint version Abstract Background Infective endocarditis (IE) is a disease caused by the involvement of pathogenic microorganisms in the endocardium, primarily characterized by the formation of growths and progressive valve damage. Despite advances in diagnostic and therapeutic methods, the mortality rate remains high. Conventional treatment typically favors surgery after 4-6 weeks of infection control. Although a series of articles on early surgical treatment have been published in recent years, outcomes for early surgical treatment continue to vary. Methods By collecting the clinical data of 166 patients who underwent cardiac surgery for IE between February 1, 2017, and January 31, 2023, we classified the patients into three groups: Group A (radical surgery within 1-7 days after admission), Group B (surgical treatment 8-13 days after admission), and Group C (surgical treatment 14-28 days after admission) according to different treatment strategies. To compare the effects of different times of surgical intervention on the early prognosis of patients, logistic multivariate regression analysis was used to determine the risk factors associated with surgical mortality, and the survival of different groups of patients was compared using Kaplan-Meier survival analysis. Results The results showed no significant differences in perioperative reinfarction, endocarditis recurrence, heart failure, or in-hospital mortality among the three treatment groups. However, ICU length of stay (P=0.015, 1.30 [1.05-1.61]), cardiac malfunction (P=0.015, 22.28 [1.82-273.04]), and other organ malfunctions (P=0.007, 29.21 [2.46-346.49]) were identified as risk factors affecting patient mortality. Conclusions Early surgical intervention did not increase the risk of death in patients with IE, nor did it increase the risk of recurrence and reoperation within one year. Therefore, we recommend early surgical intervention before completing a cycle of antibiotics in patients with a clear diagnosis, unstable cardiac function, or risk of recurrent embolism. Endocarditis Timing of surgery Early prognosis Highlights A sound and standardized endocarditis team is the best strategy to reduce mortality and improve the prognosis of patients. Surgical intervention should be performed as early as possible before completing an antibiotic cycle for patients with a clear diagnosis, unstable heart function, or the risk of repeated embolism. Introduction Infective endocarditis (IE) is a disease caused by pathogenic microorganisms that infect the endocardium and is characterized by the formation of growths and progressive valve damage. The incidence of IE is reported to be about 3–10 cases per 100,000 people, with a mortality rate of about 20% during hospitalization, increasing to 25–30% at 6 months and up to 40% at 5 years[ 1 , 2 ]. Despite improvements in diagnosis, antibiotics, and surgical treatment, early surgical intervention is recommended when antibiotics alone are not curative, when the redundant organism is large and at risk of dislodging, when peripheral arterial embolism has already occurred, or when severe cardiac insufficiency follows valvular destruction. Both American and European guidelines indicate that all decisions regarding the timing of surgical intervention for IE should be made by a multidisciplinary endocarditis team consisting of experts in infectious diseases, cardiology, and cardiac surgery, who ultimately develop an individualized treatment plan for patients with IE[ 3 ]. The traditional concept of treatment favors conventional surgery after 4–6 weeks of infection control. In recent years, a series of articles have been published comparing the therapeutic effects of early surgical treatment with those of conventional treatment, but the findings on early surgical treatment vary. Early surgical intervention, as recommended by the American College of Cardiology/American Heart Association (ACC/AHA) guidelines, is defined as ‘during the initial hospitalization and before completion of a full course of antibiotic therapy’, especially when IE complications such as severe cardiac destruction, inadequate response to antibiotic therapy, or prevention of an embolic event occur[ 3 ]. The European Society of Cardiology (ESC) guidelines, on the other hand, are more specific concerning the timing of surgery and classify the timing into the following categories: super-emergency (within 24 hours), emergency (within a few days), and elective situations (after at least 1–2 weeks of antibiotic therapy)[ 4 ]. To date, there is insufficient evidence that early surgery within days of an IE diagnosis is associated with lower mortality, and uncertainty remains about the appropriate timing of surgery. Despite the clear definition of indications for surgery in international guidelines[ 5 ], there is no consensus on the timing of surgical intervention during the active phase of infection due to the lack of evidence-based data. This is because of the risks of uncontrolled sepsis, shock, and organ failure during the acute or active phase of IE, as well as the possibility of high operative mortality and recurrence of IE caused by early surgical intervention. On the other hand, delaying surgery to complete a course of antimicrobial therapy may increase the risk of embolism, leading to extensive cardiac tissue damage, increased repair difficulties, progressive cardiogenic shock, organ failure, and ultimately increased mortality. Studies have shown that multidisciplinary endocarditis teams recommend that the time between indication for surgery and intervention should be shortened[ 6 ], but it is not clear whether early intervention is independently associated with lower mortality. Overall, the decision to operate on patients with IE is complex. Therefore, we conducted a single-center systematic review based on the tradition of multidisciplinary endocarditis team treatment of patients with IE in our center to compare the impact of surgical timing interventions on early prognosis in patients with IE, and to summarize the effectiveness of early surgical treatment options. Methods Study population and clinical data This study collected clinical data, blood cultures, and serological results from February 1, 2017, to January 31, 2023. The study was approved by the Ethics Committee of the Second Affiliated Hospital of Nanchang University ( No.2023074 ). Inclusion criteria for this study cohort were patients diagnosed with definite IE according to the latest Duke criteria[ 7 ]. All surgical patients met the indications for surgery: (i) involvement and valves with moderate-to-severe regurgitation (acute, severe left-sided regurgitation), aortic abscess or destructive penetrating lesions, congestive heart failure (New York Heart Association classification, NYHA III-IV); (ii) persistent bacteremia (not responding to antibiotic therapy), fungal infections; (iii) active valvular excrescence greater than 10 mm in diameter with clinical evidence of recurrent embolization; and (iv) prosthetic valve involvement. To maintain the independence of observation, only the first medical visit of patients with IE was used. Exclusion criteria : (i) surgery should be delayed for at least 4 weeks in the following cases: short life expectancy, multiple organ failure, combined with hemorrhagic stroke, brain abscess, or infectious cerebral aneurysm. (ii)The patient refused surgery. All patients underwent preoperative transthoracic echocardiography (TTE) or transesophageal echocardiography (TEE). The maximum length of the Vegetation length was measured by cardiac ultrasound[ 8 ] and checked for fistulae, abscesses, and perforations. The endpoints were death and a composite endpoint at 1 year. Composite endpoint events were defined as death from any cause, postoperative embolic event, recurrence of IE, postoperative valve dysfunction (PVD), and rehospitalization for heart failure. Definition Pathogenic organisms that were detected positively from heart valves, blood, and sputum included Staphylococcus spp., Streptococcus spp., Enterococcus spp., and fungi (Candida glabrata, Proximo Smooth Pseudoalbicans, Bacillus thiaminolyticus, and fungal spores). Diagnosis to admission: time from the first diagnosis of definite IE according to the latest Duke criteria to admission to our center. History of other systemic infarcts: including pulmonary, hepatic, splenic, and renal mycotic infarcts. History of the peripheral arterial system: except for vascular lesions other than large vessels, e.g., atherosclerosis, stenosis, arteriovenous fistulae, and aneurysms. Other procedures: repair of patent foramen ovale failure, pericardial stripping, atrial/ventricular septal repair, atrial thrombus removal, single internal mammary artery-bypass grafting, left auricle ligation, valvular annuloplasty, and other procedures necessary for the patient. Perioperative reinfarction: including sub/acute cerebral infarction, arterial occlusion, pulmonary embolism, etc. The degree of aortic, mitral, tricuspid, and pulmonary regurgitation was assessed using semi-quantitative or quantitative methods and categorized as mild, moderate, and severe[ 9 ]. Patient Patients were divided into three groups: Group A (radical surgery within 1–7 days of admission), Group B (surgical treatment 8–13 days after admission), and Group C (surgery 14–28 days after admission). The timing of the patient's surgery was determined through a multidisciplinary team (MDT) discussion by an endocarditis team, comprising an infectious disease specialist, a neurologist, a general surgeon assessing embolic damage to abdominal organs, and a vascular surgeon for peripheral embolism with limb ischemia. All patients with infective endocarditis (IE) who met the surgical indications for cardiac macrovascular surgery were retrospectively analyzed; 166 patients had complete data. Of these, 124 (74.7%) were males and 42 (25.3%) were females. Aortic valve endocarditis occurred in 84 (50.6%) patients, and mitral valve endocarditis in 89 (53.6%) patients, with some patients having both aortic and mitral valve involvement. Six patients (3.6%) had previously undergone valve replacement surgery (mitral or aortic valve) and developed endocarditis on the implanted prosthesis. All patients were contacted for follow-up one year after surgery, and regular clinical and echocardiographic examinations were performed according to guidelines. Operation Surgery was performed under general anesthesia with extracorporeal circulation, utilizing mild hypothermia (28°C-32°C). Twenty-two cases were conducted with small thoracoscopic incisions, while the remainder were performed with a median sternotomy. Myocardial protection was achieved using cold blood cardioplegia administered either anterogradely or retrogradely, followed by periodic administration every 30 minutes and local hypothermia to protect the myocardium. The total operative time for the cohort was 300 ± 37.5 minutes, with a cardiopulmonary bypass (CPB) time of 109 ± 25.75 minutes and an aortic cross-clamp time of 76 ± 21 minutes. The cardiac chambers and valves were meticulously examined to excise redundant tissue, damaged valves, and necrotic tissue, remove perivalvular abscesses, and based on the extent of the lesions, repair the annulus and valves, replace prosthetic chordae tendineae and valves, and repair the interventricular septum. Perivalvular septal defects and residual fistulas were also repaired. The native or prosthetic valves were completely removed and sent for microbiological culture. Fifty-seven (34.34%) patients received bioprostheses, while 109 (65.66%) received mechanical valve prostheses. Intraoperative irrigation with antibiotic solution and saline was repeatedly performed to prevent postoperative infection recurrence. Statistical method Preoperative, intraoperative, and postoperative indicators were collected from the healthcare system. First, the assumption of normality of the variable distributions was tested using the Shapiro-Wilk test. Continuous normally distributed variables were reported as mean ± standard deviation. Continuous non-normally distributed variables were reported as median with the interquartile range in parentheses, or mean with the range of values in parentheses. Categorical variables were reported as numbers and percentages. Next, risk factors associated with postoperative mortality were analyzed. All available variables were entered into a univariate logistic regression analysis to identify significant differences between survivors and deceased patients. In the second step, all variables with p-values less than 0.1 were included in a multivariate analysis using stepwise selection. Additionally, variables expressing or containing similar parameters were intentionally omitted in constructing the multivariate model to avoid covariance. Differences between groups were compared using the chi-square (χ²) test or Fisher's exact test. Continuous variables were compared using the unpaired t-test, and the Mann-Whitney U test or Kruskal-Wallis test was used in other cases. A two-sided p-value of 0.05 was considered the level of statistical significance for all tests. The overall probability of survival and the corresponding survival curves were analyzed using the Kaplan-Meier method. Analyses were performed using IBM SPSS Statistics 26 and GraphPad Prism 9 software. Results Patient characteristics Of the 308 patients diagnosed with infective endocarditis (IE), 191 (62.01%) had at least one indication for surgery, and a total of 96 patients (50.26%) were referred by the hospital. Twenty-five patients (13.09%) were excluded either because they did not undergo surgery until after the completion of antimicrobial therapy or because they refused surgery due to the high surgical risk. The remaining 166 patients (86.91%) who underwent surgery during antimicrobial treatment comprised our study cohort, with 86 patients in Group A, 51 in Group B, and 29 in Group C. Tables 1 , 2 , and 3 display the characteristics of these groups. Table 1 Preoperative Patient Basic Information on Infective Endocarditis No. (%) A(D1-7) B(D8-13) C(D14-28) N = 86 N = 51 N = 29 P Value Age, mean, years 49 ± 15.03 50 ± 13.93 48 ± 15.96 0.735 Female sex 24 (27.9) 11 (21.6) 7 (24.1) 0.703 Serum Creatinine (mg/dl) 78.77 ± 60.23 84.4 ± 51.67 78.24 ± 24.9 0.514 eGFR (ml/min/1.73 m 2 ) 90 ± 39.7 90.46 ± 61.62 95.85 ± 29.24 0.545 White blood cell count(10^ 9 /L) 7.27 ± 4.46 8.08 ± 3.59 7.93 ± 3.48 0.259 Platelet Count (10^ 9 /L) 193 ± 85.54 236 ± 90.76 195 ± 100.24 0.026 Hemoglobin(g/dl) 105 ± 21.18 105 ± 21.62 99 ± 19.85 0.167 Lactate(mmol/L) 2.5 ± 2.74 2.8 ± 1.83 2.0 ± 1.5 0.096 Causal organism (+) 46 (53.5) 35 (68.6) 19 (65.5) 0.061 Vegetation planting location 0.136 Aortic valve 46(53.5) 23(45.1) 15(51.7) 0.631 Mitral valve 43(50) 30(58.8) 16(55.2) 0.596 Vegetation length(mm) 7.2 ± 8.84 8.1 ± 7.7 8.0 ± 7 0.700 Valve perforation 37(43) 15(29.4) 13(44.8) 0.731 Echocardiographic findings Left ventricular diastolic dysfunction 46(53.5) 27(52.9) 16(55.2) 0.962 Pulmonary artery pressure 28(32.6) 11(21.6) 7(24.1) 0.398 Tricuspid regurgitation 72(83.7) 46(90.2) 25(86.2) 0.773 Mitral regurgitation 38(44.2) 19(37.3) 20(69) 0.039 Aortic regurgitation 27(31.4) 16(31.4) 7(24.1) 0.740 Pulmonic regurgitation 10(11.6) 1(2) 3(10.3) 0.134 Left ventricular ejection fraction(%) 64 ± 8.39 63 ± 6.74 64 ± 8.22 0.839 NYHA III-IV Class 71(82.6) 42(82.4) 24(82.8) 0.759 Duration between CI diagnosis and operation (days) 10 ± 23.5 4 ± 20.87 7 ± 21.06 0.195 Clinical manifestations: fever 46(53.5) 25(49) 19(65.5) 0.619 Duration of symptoms < 1 month before diagnosis 37(43) 26(51) 17(58.6) 0.304 History of disease Heart disease 29(33.7) 14(27.5) 10(34.5) 0.621 Valvular disease 32(37.2) 13(25.5) 11(37.9) 0.161 Heart failure 6(7) 8(15.7) 1(3.4) 0.161 Atrial fibrillation 12(14) 9(17.6) 4(13.8) 0.825 Neurological disease 18(20.9) 12(23.5) 8(27.6) 0.511 Abscess, Emboli 4(4.7) 6(11.8) 8(27.6) 0.003 Chronic lung disease 28(32.6) 22(43.1) 13(44.8) 0.619 Hepatic disease 9(10.5) 10(19.6) 5(17.2) 0.304 Renal insufficiency 43(50) 26(51) 12(41.4) 0.675 Peripheral arterial system diseases 6(7) 4(7.8) 1(3.4) 0.841 Type 2 diabetes mellitus 4(4.7) 7(13.7) 0(0) 0.054 Hypertension 17(19.8) 6(11.8) 9(31) 0.109 Smoker 8(9.3) 5(9.8) 3(10.3) 1.000 Drink 8(9.3) 7(13.7) 4(13.8) 0.667 Preoperative treatment time(days) 5 ± 1.68 10 ± 2.1 19 ± 7.36 0.000 Antibiotic therapy in hospital 66(76.8) 47(92.2) 29(100) 0.001 Continuous normally distributed variables were reported as mean ± standard deviation. Continuous non-normally distributed variables were reported as median with the interquartile range in parentheses, or mean with the range of values in parentheses. Categorical variables were reported as numbers and percentages. Differences between groups were compared using the chi-square (χ²) test or Fisher's exact test. Continuous variables were compared using the unpaired t-test, and the Mann-Whitney U test or Kruskal-Wallis test was used in other cases. A two-sided p -value of 0.05 was considered the level of statistical significance for all tests. Table 2 Surgical status of infective endocarditis No. (%) A(D1-7) B(D8-13) C(D14-28) N = 86 N = 51 N = 29 P Value Female surgeon 29(33.7) 12(23.5) 10(34.5) 0.660 Operation procedure Mitral valve replacement 52(60.5) 37(72.5) 14(48.3) 0.226 Aortic valve replacement 49(57) 23(45.1) 19(65.5) 0.204 Tricuspid annuloplasty 33(38.4) 22(43.1) 8(27.6) 0.384 Other operations 35(40.7) 25(49) 9(31) 0.284 mechanical valve replacement 56(65.1) 33(64.7) 20(69) 0.463 Operation time(min) 300 ± 64.47 300 ± 72.3 315 ± 54.39 0.849 Aortic clamping time(min) 76 ± 29.14 79 ± 35.96 74 ± 28.17 0.832 Extracorporeal circulation time(min) 108 ± 39.15 110 ± 43.9 106 ± 31.07 0.852 Continuous normally distributed variables were reported as mean ± standard deviation. Continuous non-normally distributed variables were reported as median with the interquartile range in parentheses, or mean with the range of values in parentheses. Categorical variables were reported as numbers and percentages. Differences between groups were compared using the chi-square (χ²) test or Fisher's exact test. Continuous variables were compared using the unpaired t-test, and the Mann-Whitney U test or Kruskal-Wallis test was used in other cases. A two-sided p -value of 0.05 was considered the level of statistical significance for all tests. Table 3 In-hospital condition of patients after surgery for infective endocarditis No. (%) A(D1-7) B(D8-13) C(D14-28) N = 86 N = 51 N = 29 P Value Postoperative intubation periods < 24h 70(81.4) 44(86.3) 24(82.8) 0.696 ICU hospitalization time(days) 3(2.5–3.5) 3(2.75–3.25) 3(2.75–3.25) 0.997 Length of hospitalization(days) 10(3–13) 9(6.5–11.5) 10(8.25–11.75) 0.258 Embolic event 2(2.3) 6(11.8) 2(6.9) 0.071 Symptomatic heart failure 11(12.8) 6(11.8) 0(0) 0.132 Other organ dysfunction 8(9.3) 4(7.8) 1(3.4) 0.684 Arrhythmia 10(11.6) 5(9.8) 2(6.9) 0.762 In-hospital mortality 5(5.8) 3(5.9) 0(0) 0.562 Echocardiographic findings Left ventricular ejection fraction (%) 58 ± 7.98 59 ± 7.67 60 ± 9.12 0.733 Tricuspid regurgitation 78(91.8) 38(77.6) 25(86.2) 0.629 Mitral regurgitation 45(52.9) 25(51) 18(62.1) 0.256 Aortic regurgitation 32(37.6) 16(32.7) 12(41.4) 0.651 Pulmonic regurgitation 10(11.8) 9(18.4) 3(10.3) 0.506 Left ventricular diastolic dysfunction 44(51.8) 30(61.2) 20(69) 0.172 Aortic transvalvular pressure difference(mmHg) 15 ± 10.08 11 ± 9.19 17 ± 12.42 0.035 NYHA III-IV Class 73(85.9) 37(75.5) 24(82.8) 0.674 Postoperative death/reoperation within 1 year 5(5.8) 4(7.8) 1(3.4) 0.665 Continuous normally distributed variables were reported as mean ± standard deviation. Continuous non-normally distributed variables were reported as median with the interquartile range in parentheses, or mean with the range of values in parentheses. Categorical variables were reported as numbers and percentages. Differences between groups were compared using the chi-square (χ²) test or Fisher's exact test. Continuous variables were compared using the unpaired t-test, and the Mann-Whitney U test or Kruskal-Wallis test was used in other cases. A two-sided p -value of 0.05 was considered the level of statistical significance for all tests. In the preoperative data, we identified differences in platelet count (P = 0.026), mitral regurgitation status (P = 0.039), and history of other systemic infarcts (P = 0.003). However, differences in the duration of preoperative treatment < 1 month and in-hospital antibiotic treatment were attributable to subgroup variations. Intraoperative data did not reveal any significant differences. Regarding perioperative data, only the in-hospital aortic transvalvular pressure difference showed a significant difference (P = 0.035). Additionally, no significant differences were observed in in-hospital mortality (P = 0.562) and death/reoperation within 1 year (P = 0.665) (Supplement Fig. 1). Effect of operation time on 1-year mortality All patients were followed up at our hospital several times within 1 year after surgery according to standard guidelines. Follow-up examinations included physical examinations, 12-lead electrocardiograms, and transthoracic echocardiograms. The in-hospital mortality rate was 4.82% (8 patients) and the reoperation rate was 1.2% (2 patients) (Table 4 ) . A univariate analysis was conducted for the death and survival groups, revealing that preoperative blood creatinine (P = 0.015), leukocyte count (P = 0.008), lactate levels (P = 0.007), NYHA classification III-IV (P = 0.04), and heart failure (P = 0.012), as well as intraoperative operative time (P = 0.017), aortic cross-clamp time (P = 0.015), and extracorporeal circulation time (P = 0.001), were significantly associated with mortality. Postoperative factors such as endotracheal intubation for < 24 hours (P = 0.001), ICU length of stay (P = 0.000), cardiac dysfunction (P = 0.000), and other organ dysfunction (P = 0.000) were also significantly associated with mortality (Table 5 ). Subsequent multifactorial analyses, adjusted for confounding variables, indicated that ICU length of stay (P = 0.015), cardiac dysfunction (P = 0.015), and other organ dysfunction (P = 0.007) remained significant predictors of mortality (Table 6 ). Table 4 Cause of death and reoperation within 1 year in the three groups of patients A(D1-7) B(D8-13) C(D14-28) In-hospital mortality N = 5 N = 3 N = 0 Infective shock 1 0 0 Low cardiac output symptom 3 2 0 Renal insufficiency 1 1 0 Cerebral hemorrhage/herniation 1 0 0 Pyemia 0 2 0 multiple organ failure 1 1 0 Cumulative results within 1 year Death N = 5 N = 3 N = 0 Reoperation N = 1 N = 1 N = 0 Statistics on causes of death and reoperations within 1 year for all three groups, counting only. Table 5 Univariate analysis of patient mortality factors Death N = 8 Alive N = 158 Logistic P Value OR for Early Surgery (95% CI) Serum Creatinine 146.19 (70.65-155.66) 80.41 (61.48–99.34) 0.015 1.01(1.00-1.02) White blood cell count 11.14 (5.64–16.65) 7.78 (5.73–9.84) 0.008 1.16(1.04–1.30) Lactate 5.84 (1.10–15.00) 3.03 (0.40–12.70) 0.007 1.29(1.07–1.55) NYHA III-IV Class 8(100) 129(81.65) 0.04 6.25(1.09–36.01) Heart disease 3(37.5) 12(7.6) 0.012 7.3(1.55–34.31) Operation time 315 (187.5-442.5) 300 (262.5-337.5) 0.017 1.01(1.01–1.02) Aortic clamping time 97.5 (56–139) 76 (55.5–96.5) 0.015 1.02(1.00-1.04) Extracorporeal circulation time 165.5 (96.13-234.88) 107.5 (84.38) 0.001 1.02(1.01–1.04) Postoperative intubation periods 4(50) 134(84.8) 0.001 2.60(1.44–4.69) ICU hospitalization time 9.38 (1–25) 3.44 (2–13) 0.000 1.56(1.23–1.98) Symptomatic heart failure 6(75) 11(7) 0.000 40.09(7.23-222.45) Other organ dysfunction 4(50) 9(5.7) 0.000 16.56(3.55–77.27) NYHA III-IV Class 5(100) 129(81.6) 0.007 14.38(2.06-100.38) Continuous normally distributed variables were reported as mean ± standard deviation. Continuous non-normally distributed variables were reported as median with the interquartile range in parentheses, or mean with the range of values in parentheses. Categorical variables were reported as numbers and percentages. Differences between groups were compared using the chi-square (χ²) test or Fisher's exact test. Continuous variables were compared using the unpaired t-test, and the Mann-Whitney U test or Kruskal-Wallis test was used in other cases. A two-sided p -value of 0.05 was considered the level of statistical significance for all tests. Table 6 Multifactorial analysis of patient mortality factors Logistic P Value OR for Early Surgery (95% CI) ICU hospitalization time 0.015 1.30(1.05–1.61) Symptomatic heart failure 0.015 22.28(1.82-273.04) Other organ dysfunction 0.007 29.21(2.46-346.49) Differences between groups were compared using the chi-square (χ²) test or Fisher's exact test. Continuous variables were compared using the unpaired t-test, and the Mann-Whitney U test or Kruskal-Wallis test was used in other cases. A two-sided p -value of 0.05 was considered the level of statistical significance for all tests. Discussion The ACC/AHA recently updated its recommendations for the surgical treatment of IE in the 2020 ACC/AHA Guidelines for the Management of Valvular Heart Disease, following earlier revisions in 2017[ 3 ]. However, the surgical recommendations for IE have remained unchanged when compared with the 2014 ACC/AHA guidelines. The role of surgery in managing IE continues to evolve, with current guidelines advocating surgical intervention for complicated left-sided infective endocarditis. Nevertheless, the optimal timing for surgical intervention remains uncertain, and the decision between completing an adequate course of antibiotic therapy and opting for early surgical intervention varies significantly across surgical centers. Hill et al. observed a four-fold increase in mortality among patients who underwent surgery within 7 days of IE diagnosis; however, this increased mortality was attributed to the severity of the IE rather than the timing of the surgery[ 10 ]. Embolism and heart failure are major contributors to mortality in IE, and the potential mortality benefit of early surgical intervention may stem from mitigating these complications[ 11 ]. Recent studies have demonstrated that early surgical intervention is associated with lower mortality compared to surgery performed 8–20 days after diagnosis. Specifically, surgical intervention within 7 days of initiating antibiotic treatment is linked to lower mortality compared to surgery performed 20 days after the start of antibiotic therapy[ 12 ]. Consequently, there is a trend towards favoring early surgical intervention in clinical practice. To assess the relationship between the timing of surgery and outcomes in IE, it is crucial to accurately determine the date of both diagnosis and surgery. While recording the date of surgery in observational studies is straightforward, accurately capturing the dates of hospitalization, definitive IE diagnosis, and the onset of complications that indicate the need for surgery can be challenging. Similarly, while the modified Duke criteria can confirm a diagnosis of definitive IE, the timing of surgical indication may be delayed by several days until complications such as heart failure symptoms, embolic events, persistent bacteremia, or intracardiac abscesses arise. This time interval between IE diagnosis and the indication for surgery can be further complicated if the patient was initially diagnosed and treated at another hospital before being transferred to a surgical center. Therefore, we conducted a detailed review of the data on symptom onset, initial medical consultation, first hospital treatment, and referral to our center for each patient with IE to comprehensively assess the disease course. Avoidance of all-cause mortality, disabling stroke, or recurrence of IE at 1 year is a more critical outcome measure for IE surgery compared to in-hospital mortality alone. Therefore, we collected and analyzed detailed data from each group of IE patients. The results indicated no significant differences in composite primary endpoints, such as mortality, incidence of postoperative complications, postoperative cardiac function, and organ dysfunction among the three groups. Additionally, there were no significant differences in postoperative endotracheal intubation duration, ICU length of stay, and total postoperative hospital days. These improvements in in-hospital clinical outcomes did not correspond to an increased risk of surgical mortality or recurrence of IE at 1 year. Studies have shown that[ 4 ] pathogenic microorganisms can be resistant to microbicidal peptides or antimicrobial agents released locally by platelets. The hypercoagulable state associated with nonbacterial thrombotic endocarditis lesions promotes fibrinogen deposition, platelet aggregation, and microbial proliferation, which contributes to infectious redundancy. Thus, while platelets may reflect the patient's physical status to some extent, they are not likely a significant factor in the primary endpoint of the mortality composite. Most cases of infective endocarditis occur in patients with pre-existing heart disease and typically involve the heart valves, with the aortic and mitral valves being the most commonly affected, while the tricuspid and pulmonary valves are less frequently involved. In patients with a longer disease duration, there is often a comorbidity with rheumatic heart disease, leading to differences in mitral regurgitation between groups. This suggests that the management of IE in patients with underlying cardiac disease may be more complex and prolonged. The results also revealed that approximately one-fifth of patients had central nervous system involvement, and systemic embolism occurred in about 10% of patients, including pulmonary, hepatic, splenic, and renal mycotic infarcts, with splenic infarcts accounting for 61% of these cases. Splenic dysfunction is generally less impactful on overall health compared to dysfunction of other organs and thus is not a significant factor in the mortality composite endpoint. It is noteworthy that the differences observed in preoperative treatment duration and in-hospital antibiotic treatment are largely attributable to subgroup variations, with extended preoperative hospital stays often resulting from prolonged antibiotic therapy and the complexity of the condition. Subsequently, we analyzed the risk factors associated with postoperative mortality by entering all variables into a logistic regression model to identify significant differences between survivors and deceased patients. The analysis revealed that ICU length of stay, postoperative cardiac malfunction, and other organ dysfunction were significant risk factors for composite endpoints such as death. ICU length of stay is known to correlate with disease severity, and postoperative organ dysfunction increases the need for advanced life support. The severity of heart failure has been shown to elevate mortality rates in patients with IE[ 13 ]. Hill et al. suggested that early surgical intervention within 7 days might reduce the incidence of heart failure[ 10 ]. Overall, the primary mortality risk factor for patients remains the state of organ dysfunction. Our 1-year follow-up results corroborate this, with organ dysfunction accounting for 69.23% of death causes. We found that the in-hospital and 1-year mortality rates were significantly lower in all three groups compared to previously reported rates[ 11 ]. Several factors may explain the lower mortality observed in our study. First, the proportion of patients with poor prognostic factors, such as moderate-to-severe congestive heart failure and staphylococcal infection (12.2% in this study), was lower than in previous studies[ 14 ]. Second, only 20.5% of patients underwent valve surgery during their initial hospitalization, and 85.5% received effective antibiotics tailored to in-hospital bacterial sensitivity. This suggests that the correct decision-making by the multidisciplinary endocarditis team and the appropriate timing of interventions may be associated with the observed low mortality rates. Third, blood cultures and echocardiography were conducted within 24 hours of hospitalization for all patients with suspected infective endocarditis. The prompt diagnosis based on established guidelines was likely associated with favorable outcomes. Finally, the patient cohort was relatively young, with a mean age close to 50 years, and the rate of reoperation and other mortality-increasing risk factors was low. However, our study has several limitations. First, this study is a retrospective data collection, which limits the design and may introduce biases. Second, the relatively small sample size prevented more detailed stratified analyses, such as propensity score matching, potentially leading to biases related to certain factors. The timing of surgical interventions after hospitalization could have influenced the study results, with patients in poorer clinical conditions possibly experiencing delays or opting against surgery. Nonetheless, all variables were rigorously reviewed to ensure high data quality. Third, preoperative treatment timing, influenced by patient symptoms, may affect prognosis. Overall, retrospective observational studies, including this one, are susceptible to survivor bias. Early surgical intervention did not increase the risk of death in patients with IE compared to those undergoing late or elective surgery, which may be attributable to the lower incidence of adverse clinical features in the early surgery group. Importantly, 1-year mortality rates were similar across all three groups and were lower than the overall patient mortality rates reported in recent literature. These findings suggest that early cardiac surgery for active infective endocarditis is not contraindicated and can be performed as soon as it is indicated, offering optimal postoperative benefits to patients. In conclusion, our team believes that establishing a strong standardised endocarditis team is essential to reduce mortality and improve patient prognosis. Early surgical intervention does not increase the risk of death in patients with IE, nor does it increase the risk of recurrence and reoperation within one year. Therefore, in patients with a clear diagnosis, unstable cardiac function, or risk of recurrent embolism, we recommend early surgical intervention before completing a cycle of antibiotic therapy. Declarations Disclosures. No. Conflict of interest. No. CRediT authorship contribution statement. Wu Liu: Writing – original draft, Resources, Methodology, Investigation, Data curation. Yongqin Li: Writing – review & editing,Writing – original draft, Heng Yang: Resources, Methodology, Data curation, Conceptualization. Congcong Li: Writing – review & editing, Resources,Methodology. Jinyu Wang: Writing – original draft, Methodology, Investigation. Wanqi Lan: Writing – original draft, Software,Resources. Yanhua Tang: Writing – review & editing, Writing – original draft, Resources, Methodology, Formal analysis, Datacuration. Funding. Key Research and Development Program of Jiangxi Province, 20223BBG71010 The Second Affiliated Hospital Of NanChang University Funding Program (No. 2021efyA02) Consent for publication All authors are aware of the content of this article, guarantee originality and authenticity, and agree to publish. Data Availability statement Data will be made available on request. Ethical statement These experiments were conducted according to established ethical guidelines, and informed consent obtained from the participants. Declaration of Interest Statement The authors declare that there are no conflicts of interest. References Cuervo G, Caballero RA, Grau Q, Pujol I, Ardanuy M, Berbel C, Gudiol D, Sánchez-Salado C, Ruiz-Majoral JC, Sbraga A, Gracia-Sánchez F, Peña L, Carratalà C. J, Twenty-Year Secular Trends in Infective Endocarditis in a Teaching Hospital. Open Forum Infect Dis; 2018 Jul. p. 27. Cahill TJ. P.B., Infective endocarditis. Lancet, 2016 Feb 27. Otto CM, Bonow NR, Carabello RO, Erwin BA, Gentile JP 3rd, Jneid F, Krieger H, Mack EV, McLeod M, O'Gara C, Rigolin PT, Sundt VH, Thompson TM 3rd, Toly A. C, 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 2021 Feb 2. Habib G, Antunes LP, Bongiorni MJ, Casalta MG, Del Zotti JP, Dulgheru F, El Khoury R, Erba G, Iung PA, Miro B, Mulder JM, Plonska-Gosciniak BJ, Price E, Roos-Hesselink S, Snygg-Martin J, Thuny U, Tornos Mas F, Vilacosta P, Zamorano I, ESC Scientific Document Group. JL;, 2015 ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J, 2015 Nov 21. Horstkotte D, Gutschik FF, Lengyel E, Oto M, Pavie A, Soler-Soler A, Thiene J, von Graevenitz G, Priori A, Garcia SG, Blanc MA, Budaj JJ, Cowie A, Dean M, Deckers V, Fernández Burgos J, Lekakis E, Lindahl J, Mazzotta B, Morais G, Oto J, Smiseth A, Lekakis OA, Vahanian J, Delahaye A, Parkhomenko F, Filipatos A, Aldershvile G, Vardas J. P; Task Force Members on Infective Endocarditis of the European Society of Cardiology; ESC Committee for Practice Guidelines (CPG); Document Reviewers., Guidelines on prevention, diagnosis and treatment of infective endocarditis executive summary; the task force on infective endocarditis of the European society of cardiology . Eur Heart J, 2004 Feb. Chirillo F, Rocco SP, Rigoli F, Borsatto R, Pedrocco F, De Leo A, Minniti A, Polesel G, Olivari E. Z., Impact of a multidisciplinary management strategy on the outcome of patients with native valve infective endocarditis. Am J Cardiol, 2013 Oct 15. Fowler VG, Selton-Suty DD, Athan C, Bayer E, Chamis AS, Dahl AL, DiBernardo A, Durante-Mangoni L, Duval E, Fortes X, Fosbøl CQ, Hannan E, Hasse MM, Hoen B, Karchmer B, Mestres AW, Petti CA, Pizzi CA, Preston MN, Roque SD, Vandenesch A, van der Meer F, van der Vaart JTM, Miro TW. JM, The 2023 Duke-International Society for Cardiovascular Infectious Diseases Criteria for Infective Endocarditis: Updating the Modified Duke Criteria. Clin Infect Dis, 2023 Aug 22. Thuny F, Belliard DSG, Avierinos O, Pergola JF, Rosenberg V, Casalta V, Gouvernet JP, Derumeaux J, Iarussi G, Ambrosi D, Calabró P, Riberi R, Collart A, Metras F, Lepidi D, Raoult H, Harle D, Weiller JR, Cohen PJ, Habib A. G, Risk of embolism and death in infective endocarditis: prognostic value of echocardiography: a prospective multicenter study. Circulation, 2005 Jul 5. Zoghbi WA, Foster E-SM, Grayburn E, Kraft PA, Levine CD, Nihoyannopoulos RA, Otto P, Quinones CM, Rakowski MA, Stewart H, Waggoner WJ, Weissman A. NJ; American Society of Echocardiography, Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography . J Am Soc Echocardiogr, 2003 Jul. Hill EE, Vanderschueren HM, Claus S, Peetermans P, Herijgers WE. P, Outcome of patients requiring valve surgery during active infective endocarditis. Ann Thorac Surg. Ann Thorac Surg, 2008 May. Kang DH, Kim KY, Sun SH, Kim BJ, Yun DH, Song SC, Choo JM, Chung SJ, Song CH, Lee JK, Sohn JW. DW, Early surgery versus conventional treatment for infective endocarditis. N Engl J Med, 2012 Jun 28. Anantha Narayanan M, Kalil MHT, Kanmanthareddy AC, Suri A, Mansour RM, Destache G, Baskaran CJ, Mooss J, Wichman AN, Morrow T, Vivekanandan L. R, Early versus late surgical intervention or medical management for infective endocarditis: a systematic review and meta-analysis. Heart, 2016 Jun 15. Kiefer T, Tribouilloy PL, Cortes C, Casillo C, Chu R, Delahaye V, Durante-Mangoni F, Edathodu E, Falces J, Logar C, Miró M, Naber JM, Tripodi C, Murdoch MF, Moreillon DR, Utili P, Wang R. A, Association between valvular surgery and mortality among patients with infective endocarditis complicated by heart failure. JAMA, 2011 Nov 23. Lalani T, Benjamin CC, Lasca DK, Naber O, Fowler C, Corey VG Jr, Chu GR, Fenely VH, Pachirat M, Tan O, Watkin RS, Ionac R, Moreno A, Mestres A, Casabé CA, Chipigina J, Eisen N, Spelman DP, Delahaye D, Peterson F, Olaison G, Wang L. A, International Collaboration on Endocarditis-Prospective Cohort Study (ICE-PCS) Investigators. Analysis of the impact of early surgery on in-hospital mortality of native valve endocarditis: use of propensity score and instrumental variable methods to adjust for treatment-selection bias. Circulation, 2010 Mar 2. Supplement Fig. 1: Kaplan-Meier survival analysis of three groups of patients. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6760790","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":486548080,"identity":"7681cf23-b95d-4247-b1bf-3c00f6f91149","order_by":0,"name":"Wu Liu","email":"","orcid":"","institution":"The Second Affiliated Hospital of Nanchang University","correspondingAuthor":false,"prefix":"","firstName":"Wu","middleName":"","lastName":"Liu","suffix":""},{"id":486548081,"identity":"a3bb6b39-c67e-43df-9acf-bcf832ed4164","order_by":1,"name":"Yongqin Li","email":"","orcid":"","institution":"The Second Affiliated Hospital of Nanchang University","correspondingAuthor":false,"prefix":"","firstName":"Yongqin","middleName":"","lastName":"Li","suffix":""},{"id":486548082,"identity":"4ef2c84b-20aa-4d90-b287-c75ee38c8c7e","order_by":2,"name":"Heng Yang","email":"","orcid":"","institution":"The Second Affiliated Hospital of Nanchang University","correspondingAuthor":false,"prefix":"","firstName":"Heng","middleName":"","lastName":"Yang","suffix":""},{"id":486548083,"identity":"a7fcb09a-c549-4de3-a631-94cc11429c41","order_by":3,"name":"Jingyu Wang","email":"","orcid":"","institution":"The Second Clinical Medical College of Nanchang University","correspondingAuthor":false,"prefix":"","firstName":"Jingyu","middleName":"","lastName":"Wang","suffix":""},{"id":486548084,"identity":"38206542-3212-4447-a78f-2fd08ce43724","order_by":4,"name":"Wanqi Lan","email":"","orcid":"","institution":"The Second Affiliated Hospital of Nanchang University","correspondingAuthor":false,"prefix":"","firstName":"Wanqi","middleName":"","lastName":"Lan","suffix":""},{"id":486548085,"identity":"882a5eb4-9c09-4c2f-8e1d-c16cf98c6c8e","order_by":5,"name":"Congcong Li","email":"","orcid":"","institution":"The Second Affiliated Hospital of Nanchang University","correspondingAuthor":false,"prefix":"","firstName":"Congcong","middleName":"","lastName":"Li","suffix":""},{"id":486548086,"identity":"a08e03d1-e1df-4358-9bdf-d1d0519c64e6","order_by":6,"name":"Yanhua Tang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAvUlEQVRIiWNgGAWjYFACHsbHPyr+ybGxtx8gUgMDD7Mxw5kDxnw8ZxKI1sImzNhyIHGehIMBcVrsJXKPMRc23Elvk2BIYPhRsY0IWyTy0h7P3PEst0268QBjz5nbxGjJMTfgPcOc2yZzIIGZsY04LWYSvG3M6WwSCQbEa5HmbTucQIKWM2+MDWecSTNsAwbyQaL8wt6eY/jgQ4WNvHx7+8EHPyqI0MIgkIBgHyBCPRDwE6luFIyCUTAKRjAAALecPFWw2w9iAAAAAElFTkSuQmCC","orcid":"","institution":"The Second Affiliated Hospital of Nanchang University","correspondingAuthor":true,"prefix":"","firstName":"Yanhua","middleName":"","lastName":"Tang","suffix":""}],"badges":[],"createdAt":"2025-05-27 15:08:35","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6760790/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6760790/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13019-025-03766-3","type":"published","date":"2025-12-23T15:57:58+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":99172365,"identity":"26cd8069-3c64-4c71-93ea-e114f0592fc9","added_by":"auto","created_at":"2025-12-29 16:08:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":847609,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6760790/v1/c0444af3-8f51-45f2-961b-ae71d5088006.pdf"},{"id":86960748,"identity":"ad07f62a-1173-424c-8746-a4fc65a68a78","added_by":"auto","created_at":"2025-07-17 16:06:13","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":57870,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementFigure1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6760790/v1/804c719375b0eb9cd2dcb67d.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eCardiac surgery timing on the prognosis of patients with infective endocarditis\u003c/p\u003e","fulltext":[{"header":"Highlights","content":"\u003cul start=\"50\"\u003e\n \u003cli\u003eA sound and standardized endocarditis team is the best strategy to reduce mortality and improve the prognosis of patients.\u003c/li\u003e\n \u003cli\u003eSurgical intervention should be performed as early as possible before completing an antibiotic cycle for patients with a clear diagnosis, unstable heart function, or the risk of repeated embolism.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003eInfective endocarditis (IE) is a disease caused by pathogenic microorganisms that infect the endocardium and is characterized by the formation of growths and progressive valve damage. The incidence of IE is reported to be about 3\u0026ndash;10 cases per 100,000 people, with a mortality rate of about 20% during hospitalization, increasing to 25\u0026ndash;30% at 6 months and up to 40% at 5 years[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Despite improvements in diagnosis, antibiotics, and surgical treatment, early surgical intervention is recommended when antibiotics alone are not curative, when the redundant organism is large and at risk of dislodging, when peripheral arterial embolism has already occurred, or when severe cardiac insufficiency follows valvular destruction. Both American and European guidelines indicate that all decisions regarding the timing of surgical intervention for IE should be made by a multidisciplinary endocarditis team consisting of experts in infectious diseases, cardiology, and cardiac surgery, who ultimately develop an individualized treatment plan for patients with IE[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe traditional concept of treatment favors conventional surgery after 4\u0026ndash;6 weeks of infection control. In recent years, a series of articles have been published comparing the therapeutic effects of early surgical treatment with those of conventional treatment, but the findings on early surgical treatment vary. Early surgical intervention, as recommended by the American College of Cardiology/American Heart Association (ACC/AHA) guidelines, is defined as \u0026lsquo;during the initial hospitalization and before completion of a full course of antibiotic therapy\u0026rsquo;, especially when IE complications such as severe cardiac destruction, inadequate response to antibiotic therapy, or prevention of an embolic event occur[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The European Society of Cardiology (ESC) guidelines, on the other hand, are more specific concerning the timing of surgery and classify the timing into the following categories: super-emergency (within 24 hours), emergency (within a few days), and elective situations (after at least 1\u0026ndash;2 weeks of antibiotic therapy)[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTo date, there is insufficient evidence that early surgery within days of an IE diagnosis is associated with lower mortality, and uncertainty remains about the appropriate timing of surgery. Despite the clear definition of indications for surgery in international guidelines[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], there is no consensus on the timing of surgical intervention during the active phase of infection due to the lack of evidence-based data. This is because of the risks of uncontrolled sepsis, shock, and organ failure during the acute or active phase of IE, as well as the possibility of high operative mortality and recurrence of IE caused by early surgical intervention. On the other hand, delaying surgery to complete a course of antimicrobial therapy may increase the risk of embolism, leading to extensive cardiac tissue damage, increased repair difficulties, progressive cardiogenic shock, organ failure, and ultimately increased mortality. Studies have shown that multidisciplinary endocarditis teams recommend that the time between indication for surgery and intervention should be shortened[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], but it is not clear whether early intervention is independently associated with lower mortality.\u003c/p\u003e\u003cp\u003eOverall, the decision to operate on patients with IE is complex. Therefore, we conducted a single-center systematic review based on the tradition of multidisciplinary endocarditis team treatment of patients with IE in our center to compare the impact of surgical timing interventions on early prognosis in patients with IE, and to summarize the effectiveness of early surgical treatment options.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy population and clinical data\u003c/p\u003e\u003cp\u003eThis study collected clinical data, blood cultures, and serological results from February 1, 2017, to January 31, 2023. The study was approved by \u003cb\u003ethe Ethics Committee of the Second Affiliated Hospital of Nanchang University\u003c/b\u003e (\u003cb\u003eNo.2023074\u003c/b\u003e). Inclusion criteria for this study cohort were patients diagnosed with definite IE according to the latest Duke criteria[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. All surgical patients met the indications for surgery: (i) involvement and valves with moderate-to-severe regurgitation (acute, severe left-sided regurgitation), aortic abscess or destructive penetrating lesions, congestive heart failure (New York Heart Association classification, NYHA III-IV); (ii) persistent bacteremia (not responding to antibiotic therapy), fungal infections; (iii) active valvular excrescence greater than 10 mm in diameter with clinical evidence of recurrent embolization; and (iv) prosthetic valve involvement. To maintain the independence of observation, only the first medical visit of patients with IE was used. Exclusion criteria : (i) surgery should be delayed for at least 4 weeks in the following cases: short life expectancy, multiple organ failure, combined with hemorrhagic stroke, brain abscess, or infectious cerebral aneurysm. (ii)The patient refused surgery. All patients underwent preoperative transthoracic echocardiography (TTE) or transesophageal echocardiography (TEE). The maximum length of the Vegetation length was measured by cardiac ultrasound[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] and checked for fistulae, abscesses, and perforations. The endpoints were death and a composite endpoint at 1 year. Composite endpoint events were defined as death from any cause, postoperative embolic event, recurrence of IE, postoperative valve dysfunction (PVD), and rehospitalization for heart failure.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eDefinition\u003c/strong\u003e\u003cp\u003ePathogenic organisms that were detected positively from heart valves, blood, and sputum included Staphylococcus spp., Streptococcus spp., Enterococcus spp., and fungi (Candida glabrata, Proximo Smooth Pseudoalbicans, Bacillus thiaminolyticus, and fungal spores). Diagnosis to admission: time from the first diagnosis of definite IE according to the latest Duke criteria to admission to our center. History of other systemic infarcts: including pulmonary, hepatic, splenic, and renal mycotic infarcts. History of the peripheral arterial system: except for vascular lesions other than large vessels, e.g., atherosclerosis, stenosis, arteriovenous fistulae, and aneurysms. Other procedures: repair of patent foramen ovale failure, pericardial stripping, atrial/ventricular septal repair, atrial thrombus removal, single internal mammary artery-bypass grafting, left auricle ligation, valvular annuloplasty, and other procedures necessary for the patient. Perioperative reinfarction: including sub/acute cerebral infarction, arterial occlusion, pulmonary embolism, etc. The degree of aortic, mitral, tricuspid, and pulmonary regurgitation was assessed using semi-quantitative or quantitative methods and categorized as mild, moderate, and severe[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003c/p\u003e\u003cp\u003ePatient\u003c/p\u003e\u003cp\u003ePatients were divided into three groups: Group A (radical surgery within 1\u0026ndash;7 days of admission), Group B (surgical treatment 8\u0026ndash;13 days after admission), and Group C (surgery 14\u0026ndash;28 days after admission). The timing of the patient's surgery was determined through a multidisciplinary team (MDT) discussion by an endocarditis team, comprising an infectious disease specialist, a neurologist, a general surgeon assessing embolic damage to abdominal organs, and a vascular surgeon for peripheral embolism with limb ischemia. All patients with infective endocarditis (IE) who met the surgical indications for cardiac macrovascular surgery were retrospectively analyzed; 166 patients had complete data. Of these, 124 (74.7%) were males and 42 (25.3%) were females. Aortic valve endocarditis occurred in 84 (50.6%) patients, and mitral valve endocarditis in 89 (53.6%) patients, with some patients having both aortic and mitral valve involvement. Six patients (3.6%) had previously undergone valve replacement surgery (mitral or aortic valve) and developed endocarditis on the implanted prosthesis. All patients were contacted for follow-up one year after surgery, and regular clinical and echocardiographic examinations were performed according to guidelines.\u003c/p\u003e\u003cp\u003eOperation\u003c/p\u003e\u003cp\u003eSurgery was performed under general anesthesia with extracorporeal circulation, utilizing mild hypothermia (28\u0026deg;C-32\u0026deg;C). Twenty-two cases were conducted with small thoracoscopic incisions, while the remainder were performed with a median sternotomy. Myocardial protection was achieved using cold blood cardioplegia administered either anterogradely or retrogradely, followed by periodic administration every 30 minutes and local hypothermia to protect the myocardium. The total operative time for the cohort was 300\u0026thinsp;\u0026plusmn;\u0026thinsp;37.5 minutes, with a cardiopulmonary bypass (CPB) time of 109\u0026thinsp;\u0026plusmn;\u0026thinsp;25.75 minutes and an aortic cross-clamp time of 76\u0026thinsp;\u0026plusmn;\u0026thinsp;21 minutes. The cardiac chambers and valves were meticulously examined to excise redundant tissue, damaged valves, and necrotic tissue, remove perivalvular abscesses, and based on the extent of the lesions, repair the annulus and valves, replace prosthetic chordae tendineae and valves, and repair the interventricular septum. Perivalvular septal defects and residual fistulas were also repaired. The native or prosthetic valves were completely removed and sent for microbiological culture. Fifty-seven (34.34%) patients received bioprostheses, while 109 (65.66%) received mechanical valve prostheses. Intraoperative irrigation with antibiotic solution and saline was repeatedly performed to prevent postoperative infection recurrence.\u003c/p\u003e\u003cp\u003eStatistical method\u003c/p\u003e\u003cp\u003ePreoperative, intraoperative, and postoperative indicators were collected from the healthcare system. First, the assumption of normality of the variable distributions was tested using the Shapiro-Wilk test. Continuous normally distributed variables were reported as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation. Continuous non-normally distributed variables were reported as median with the interquartile range in parentheses, or mean with the range of values in parentheses. Categorical variables were reported as numbers and percentages. Next, risk factors associated with postoperative mortality were analyzed. All available variables were entered into a univariate logistic regression analysis to identify significant differences between survivors and deceased patients. In the second step, all variables with p-values less than 0.1 were included in a multivariate analysis using stepwise selection. Additionally, variables expressing or containing similar parameters were intentionally omitted in constructing the multivariate model to avoid covariance.\u003c/p\u003e\u003cp\u003eDifferences between groups were compared using the chi-square (χ\u0026sup2;) test or Fisher's exact test. Continuous variables were compared using the unpaired t-test, and the Mann-Whitney U test or Kruskal-Wallis test was used in other cases. A two-sided p-value of 0.05 was considered the level of statistical significance for all tests. The overall probability of survival and the corresponding survival curves were analyzed using the Kaplan-Meier method. Analyses were performed using IBM SPSS Statistics 26 and GraphPad Prism 9 software.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003ePatient characteristics\u003c/p\u003e\u003cp\u003eOf the 308 patients diagnosed with infective endocarditis (IE), 191 (62.01%) had at least one indication for surgery, and a total of 96 patients (50.26%) were referred by the hospital. Twenty-five patients (13.09%) were excluded either because they did not undergo surgery until after the completion of antimicrobial therapy or because they refused surgery due to the high surgical risk. The remaining 166 patients (86.91%) who underwent surgery during antimicrobial treatment comprised our study cohort, with 86 patients in Group A, 51 in Group B, and 29 in Group C. Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, and \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e display the characteristics of these groups.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePreoperative Patient Basic Information on Infective Endocarditis\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo. (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eA(D1-7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eB(D8-13)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eC(D14-28)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP Value\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge,\u003c/p\u003e\u003cp\u003emean, years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e49\u0026thinsp;\u0026plusmn;\u0026thinsp;15.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50\u0026thinsp;\u0026plusmn;\u0026thinsp;13.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e48\u0026thinsp;\u0026plusmn;\u0026thinsp;15.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.735\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale sex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24 (27.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11 (21.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7 (24.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.703\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSerum Creatinine (mg/dl)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e78.77\u0026thinsp;\u0026plusmn;\u0026thinsp;60.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e84.4\u0026thinsp;\u0026plusmn;\u0026thinsp;51.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e78.24\u0026thinsp;\u0026plusmn;\u0026thinsp;24.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.514\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eeGFR\u003c/p\u003e\u003cp\u003e(ml/min/1.73 m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e90\u0026thinsp;\u0026plusmn;\u0026thinsp;39.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e90.46\u0026thinsp;\u0026plusmn;\u0026thinsp;61.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e95.85\u0026thinsp;\u0026plusmn;\u0026thinsp;29.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.545\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWhite blood cell count(10^\u003csup\u003e9\u003c/sup\u003e/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7.27\u0026thinsp;\u0026plusmn;\u0026thinsp;4.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.08\u0026thinsp;\u0026plusmn;\u0026thinsp;3.59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.93\u0026thinsp;\u0026plusmn;\u0026thinsp;3.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.259\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePlatelet Count\u003c/p\u003e\u003cp\u003e(10^\u003csup\u003e9\u003c/sup\u003e/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e193\u0026thinsp;\u0026plusmn;\u0026thinsp;85.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e236\u0026thinsp;\u0026plusmn;\u0026thinsp;90.76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e195\u0026thinsp;\u0026plusmn;\u0026thinsp;100.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.026\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHemoglobin(g/dl)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e105\u0026thinsp;\u0026plusmn;\u0026thinsp;21.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e105\u0026thinsp;\u0026plusmn;\u0026thinsp;21.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e99\u0026thinsp;\u0026plusmn;\u0026thinsp;19.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.167\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLactate(mmol/L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.096\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCausal organism (+)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e46 (53.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35 (68.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e19 (65.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.061\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003eVegetation planting location\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.136\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAortic valve\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e46(53.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23(45.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15(51.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.631\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMitral valve\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e43(50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30(58.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16(55.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.596\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVegetation length(mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7.2\u0026thinsp;\u0026plusmn;\u0026thinsp;8.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.1\u0026thinsp;\u0026plusmn;\u0026thinsp;7.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8.0\u0026thinsp;\u0026plusmn;\u0026thinsp;7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.700\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eValve perforation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e37(43)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15(29.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13(44.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.731\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eEchocardiographic findings\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeft ventricular diastolic dysfunction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e46(53.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27(52.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16(55.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.962\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePulmonary artery pressure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e28(32.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11(21.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7(24.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.398\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTricuspid regurgitation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e72(83.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e46(90.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25(86.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.773\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMitral regurgitation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e38(44.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19(37.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20(69)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.039\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAortic regurgitation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27(31.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16(31.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7(24.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.740\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePulmonic regurgitation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10(11.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1(2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3(10.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.134\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeft ventricular ejection fraction(%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e64\u0026thinsp;\u0026plusmn;\u0026thinsp;8.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e63\u0026thinsp;\u0026plusmn;\u0026thinsp;6.74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e64\u0026thinsp;\u0026plusmn;\u0026thinsp;8.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.839\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNYHA III-IV Class\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e71(82.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42(82.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24(82.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.759\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDuration between CI diagnosis and operation (days)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10\u0026thinsp;\u0026plusmn;\u0026thinsp;23.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u0026thinsp;\u0026plusmn;\u0026thinsp;20.87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7\u0026thinsp;\u0026plusmn;\u0026thinsp;21.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.195\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClinical manifestations: fever\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e46(53.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25(49)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e19(65.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.619\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDuration of symptoms\u0026thinsp;\u0026lt;\u0026thinsp;1 month before diagnosis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e37(43)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26(51)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17(58.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.304\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eHistory of disease\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHeart disease\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e29(33.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14(27.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10(34.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.621\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eValvular disease\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e32(37.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13(25.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11(37.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.161\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHeart failure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6(7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8(15.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1(3.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.161\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAtrial fibrillation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12(14)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9(17.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4(13.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.825\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNeurological disease\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18(20.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12(23.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8(27.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.511\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAbscess, Emboli\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4(4.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6(11.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8(27.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChronic lung disease\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e28(32.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22(43.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13(44.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.619\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHepatic disease\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9(10.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10(19.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5(17.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.304\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRenal insufficiency\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e43(50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26(51)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12(41.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.675\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePeripheral arterial system diseases\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6(7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4(7.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1(3.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.841\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eType 2 diabetes mellitus\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4(4.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7(13.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0(0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.054\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHypertension\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17(19.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6(11.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9(31)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.109\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSmoker\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8(9.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5(9.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3(10.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDrink\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8(9.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7(13.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4(13.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.667\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePreoperative treatment time(days)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e19\u0026thinsp;\u0026plusmn;\u0026thinsp;7.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAntibiotic therapy in hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e66(76.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e47(92.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e29(100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eContinuous normally distributed variables were reported as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation. Continuous non-normally distributed variables were reported as median with the interquartile range in parentheses, or mean with the range of values in parentheses. Categorical variables were reported as numbers and percentages. Differences between groups were compared using the chi-square (χ\u0026sup2;) test or Fisher's exact test. Continuous variables were compared using the unpaired t-test, and the Mann-Whitney U test or Kruskal-Wallis test was used in other cases. A two-sided \u003cem\u003ep\u003c/em\u003e-value of 0.05 was considered the level of statistical significance for all tests.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSurgical status of infective endocarditis\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo. (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eA(D1-7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eB(D8-13)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eC(D14-28)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP Value\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale surgeon\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e29(33.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12(23.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10(34.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.660\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eOperation procedure\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMitral valve replacement\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e52(60.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e37(72.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14(48.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.226\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAortic valve replacement\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e49(57)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23(45.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e19(65.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.204\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTricuspid annuloplasty\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e33(38.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22(43.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8(27.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.384\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther operations\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e35(40.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25(49)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9(31)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.284\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003emechanical valve replacement\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e56(65.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33(64.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20(69)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.463\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOperation time(min)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e300\u0026thinsp;\u0026plusmn;\u0026thinsp;64.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e300\u0026thinsp;\u0026plusmn;\u0026thinsp;72.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e315\u0026thinsp;\u0026plusmn;\u0026thinsp;54.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.849\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAortic clamping time(min)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e76\u0026thinsp;\u0026plusmn;\u0026thinsp;29.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e79\u0026thinsp;\u0026plusmn;\u0026thinsp;35.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e74\u0026thinsp;\u0026plusmn;\u0026thinsp;28.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.832\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExtracorporeal circulation time(min)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e108\u0026thinsp;\u0026plusmn;\u0026thinsp;39.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e110\u0026thinsp;\u0026plusmn;\u0026thinsp;43.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e106\u0026thinsp;\u0026plusmn;\u0026thinsp;31.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.852\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eContinuous normally distributed variables were reported as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation. Continuous non-normally distributed variables were reported as median with the interquartile range in parentheses, or mean with the range of values in parentheses. Categorical variables were reported as numbers and percentages. Differences between groups were compared using the chi-square (χ\u0026sup2;) test or Fisher's exact test. Continuous variables were compared using the unpaired t-test, and the Mann-Whitney U test or Kruskal-Wallis test was used in other cases. A two-sided \u003cem\u003ep\u003c/em\u003e-value of 0.05 was considered the level of statistical significance for all tests.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eIn-hospital condition of patients after surgery for infective endocarditis\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo. (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eA(D1-7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eB(D8-13)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eC(D14-28)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP Value\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePostoperative intubation periods\u0026thinsp;\u0026lt;\u0026thinsp;24h\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e70(81.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e44(86.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24(82.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.696\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eICU hospitalization time(days)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3(2.5\u0026ndash;3.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3(2.75\u0026ndash;3.25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3(2.75\u0026ndash;3.25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.997\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLength of hospitalization(days)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10(3\u0026ndash;13)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9(6.5\u0026ndash;11.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10(8.25\u0026ndash;11.75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.258\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmbolic event\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2(2.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6(11.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2(6.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.071\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSymptomatic heart failure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11(12.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6(11.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0(0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.132\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther organ dysfunction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8(9.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4(7.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1(3.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.684\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eArrhythmia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10(11.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5(9.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2(6.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.762\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIn-hospital mortality\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5(5.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3(5.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0(0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.562\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eEchocardiographic findings\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeft ventricular ejection fraction (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e58\u0026thinsp;\u0026plusmn;\u0026thinsp;7.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e59\u0026thinsp;\u0026plusmn;\u0026thinsp;7.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e60\u0026thinsp;\u0026plusmn;\u0026thinsp;9.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.733\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTricuspid regurgitation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e78(91.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e38(77.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25(86.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.629\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMitral regurgitation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e45(52.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25(51)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18(62.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.256\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAortic regurgitation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e32(37.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16(32.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12(41.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.651\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePulmonic regurgitation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10(11.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9(18.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3(10.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.506\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeft ventricular diastolic dysfunction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e44(51.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30(61.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20(69)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.172\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAortic transvalvular pressure difference(mmHg)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15\u0026thinsp;\u0026plusmn;\u0026thinsp;10.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11\u0026thinsp;\u0026plusmn;\u0026thinsp;9.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17\u0026thinsp;\u0026plusmn;\u0026thinsp;12.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.035\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNYHA III-IV Class\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e73(85.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e37(75.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24(82.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.674\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePostoperative death/reoperation within 1 year\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5(5.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4(7.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1(3.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.665\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eContinuous normally distributed variables were reported as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation. Continuous non-normally distributed variables were reported as median with the interquartile range in parentheses, or mean with the range of values in parentheses. Categorical variables were reported as numbers and percentages. Differences between groups were compared using the chi-square (χ\u0026sup2;) test or Fisher's exact test. Continuous variables were compared using the unpaired t-test, and the Mann-Whitney U test or Kruskal-Wallis test was used in other cases. A two-sided \u003cem\u003ep\u003c/em\u003e-value of 0.05 was considered the level of statistical significance for all tests.\u003c/p\u003e\u003cp\u003eIn the preoperative data, we identified differences in platelet count (P\u0026thinsp;=\u0026thinsp;0.026), mitral regurgitation status (P\u0026thinsp;=\u0026thinsp;0.039), and history of other systemic infarcts (P\u0026thinsp;=\u0026thinsp;0.003). However, differences in the duration of preoperative treatment\u0026thinsp;\u0026lt;\u0026thinsp;1 month and in-hospital antibiotic treatment were attributable to subgroup variations. Intraoperative data did not reveal any significant differences. Regarding perioperative data, only the in-hospital aortic transvalvular pressure difference showed a significant difference (P\u0026thinsp;=\u0026thinsp;0.035). Additionally, no significant differences were observed in in-hospital mortality (P\u0026thinsp;=\u0026thinsp;0.562) and death/reoperation within 1 year (P\u0026thinsp;=\u0026thinsp;0.665) (Supplement Fig.\u0026nbsp;1).\u003c/p\u003e\u003cp\u003eEffect of operation time on 1-year mortality\u003c/p\u003e\u003cp\u003e All patients were followed up at our hospital several times within 1 year after surgery according to standard guidelines. Follow-up examinations included physical examinations, 12-lead electrocardiograms, and transthoracic echocardiograms. The in-hospital mortality rate was 4.82% (8 patients) and the reoperation rate was 1.2% (2 patients) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. A univariate analysis was conducted for the death and survival groups, revealing that preoperative blood creatinine (P\u0026thinsp;=\u0026thinsp;0.015), leukocyte count (P\u0026thinsp;=\u0026thinsp;0.008), lactate levels (P\u0026thinsp;=\u0026thinsp;0.007), NYHA classification III-IV (P\u0026thinsp;=\u0026thinsp;0.04), and heart failure (P\u0026thinsp;=\u0026thinsp;0.012), as well as intraoperative operative time (P\u0026thinsp;=\u0026thinsp;0.017), aortic cross-clamp time (P\u0026thinsp;=\u0026thinsp;0.015), and extracorporeal circulation time (P\u0026thinsp;=\u0026thinsp;0.001), were significantly associated with mortality. Postoperative factors such as endotracheal intubation for \u0026lt;\u0026thinsp;24 hours (P\u0026thinsp;=\u0026thinsp;0.001), ICU length of stay (P\u0026thinsp;=\u0026thinsp;0.000), cardiac dysfunction (P\u0026thinsp;=\u0026thinsp;0.000), and other organ dysfunction (P\u0026thinsp;=\u0026thinsp;0.000) were also significantly associated with mortality (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Subsequent multifactorial analyses, adjusted for confounding variables, indicated that ICU length of stay (P\u0026thinsp;=\u0026thinsp;0.015), cardiac dysfunction (P\u0026thinsp;=\u0026thinsp;0.015), and other organ dysfunction (P\u0026thinsp;=\u0026thinsp;0.007) remained significant predictors of mortality (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCause of death and reoperation within 1 year in the three groups of patients\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eA(D1-7)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eB(D8-13)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eC(D14-28)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIn-hospital mortality\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInfective shock\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLow cardiac output symptom\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRenal insufficiency\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCerebral hemorrhage/herniation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePyemia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003emultiple organ failure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003eCumulative results within 1 year\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDeath\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReoperation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eStatistics on causes of death and reoperations within 1 year for all three groups, counting only.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eUnivariate analysis of patient mortality factors\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDeath N\u0026thinsp;=\u0026thinsp;8\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAlive N\u0026thinsp;=\u0026thinsp;158\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLogistic P Value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eOR for Early Surgery (95% CI)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSerum Creatinine\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e146.19\u003c/p\u003e\u003cp\u003e(70.65-155.66)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e80.41\u003c/p\u003e\u003cp\u003e(61.48\u0026ndash;99.34)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.015\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.01(1.00-1.02)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWhite blood cell count\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11.14\u003c/p\u003e\u003cp\u003e(5.64\u0026ndash;16.65)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7.78\u003c/p\u003e\u003cp\u003e(5.73\u0026ndash;9.84)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.008\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.16(1.04\u0026ndash;1.30)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLactate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5.84\u003c/p\u003e\u003cp\u003e(1.10\u0026ndash;15.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.03\u003c/p\u003e\u003cp\u003e(0.40\u0026ndash;12.70)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.007\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.29(1.07\u0026ndash;1.55)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNYHA III-IV Class\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8(100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e129(81.65)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6.25(1.09\u0026ndash;36.01)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHeart disease\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3(37.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12(7.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.012\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7.3(1.55\u0026ndash;34.31)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOperation time\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e315\u003c/p\u003e\u003cp\u003e(187.5-442.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e300\u003c/p\u003e\u003cp\u003e(262.5-337.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.017\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.01(1.01\u0026ndash;1.02)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAortic clamping time\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e97.5\u003c/p\u003e\u003cp\u003e(56\u0026ndash;139)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e76\u003c/p\u003e\u003cp\u003e(55.5\u0026ndash;96.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.015\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.02(1.00-1.04)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExtracorporeal circulation time\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e165.5\u003c/p\u003e\u003cp\u003e(96.13-234.88)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e107.5\u003c/p\u003e\u003cp\u003e(84.38)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.02(1.01\u0026ndash;1.04)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePostoperative intubation periods\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4(50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e134(84.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.60(1.44\u0026ndash;4.69)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eICU hospitalization time\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9.38\u003c/p\u003e\u003cp\u003e(1\u0026ndash;25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.44\u003c/p\u003e\u003cp\u003e(2\u0026ndash;13)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.56(1.23\u0026ndash;1.98)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSymptomatic heart failure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6(75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11(7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e40.09(7.23-222.45)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther organ dysfunction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4(50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9(5.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e16.56(3.55\u0026ndash;77.27)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNYHA III-IV Class\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5(100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e129(81.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.007\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e14.38(2.06-100.38)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eContinuous normally distributed variables were reported as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation. Continuous non-normally distributed variables were reported as median with the interquartile range in parentheses, or mean with the range of values in parentheses. Categorical variables were reported as numbers and percentages. Differences between groups were compared using the chi-square (χ\u0026sup2;) test or Fisher's exact test. Continuous variables were compared using the unpaired t-test, and the Mann-Whitney U test or Kruskal-Wallis test was used in other cases. A two-sided \u003cem\u003ep\u003c/em\u003e-value of 0.05 was considered the level of statistical significance for all tests.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMultifactorial analysis of patient mortality factors\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLogistic P Value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOR for Early Surgery (95% CI)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eICU hospitalization time\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.015\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1.30(1.05\u0026ndash;1.61)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSymptomatic heart failure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.015\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e22.28(1.82-273.04)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther organ dysfunction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.007\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e29.21(2.46-346.49)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eDifferences between groups were compared using the chi-square (χ\u0026sup2;) test or Fisher's exact test. Continuous variables were compared using the unpaired t-test, and the Mann-Whitney U test or Kruskal-Wallis test was used in other cases. A two-sided \u003cem\u003ep\u003c/em\u003e-value of 0.05 was considered the level of statistical significance for all tests.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe ACC/AHA recently updated its recommendations for the surgical treatment of IE in the 2020 ACC/AHA Guidelines for the Management of Valvular Heart Disease, following earlier revisions in 2017[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, the surgical recommendations for IE have remained unchanged when compared with the 2014 ACC/AHA guidelines. The role of surgery in managing IE continues to evolve, with current guidelines advocating surgical intervention for complicated left-sided infective endocarditis. Nevertheless, the optimal timing for surgical intervention remains uncertain, and the decision between completing an adequate course of antibiotic therapy and opting for early surgical intervention varies significantly across surgical centers. Hill et al. observed a four-fold increase in mortality among patients who underwent surgery within 7 days of IE diagnosis; however, this increased mortality was attributed to the severity of the IE rather than the timing of the surgery[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Embolism and heart failure are major contributors to mortality in IE, and the potential mortality benefit of early surgical intervention may stem from mitigating these complications[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Recent studies have demonstrated that early surgical intervention is associated with lower mortality compared to surgery performed 8\u0026ndash;20 days after diagnosis. Specifically, surgical intervention within 7 days of initiating antibiotic treatment is linked to lower mortality compared to surgery performed 20 days after the start of antibiotic therapy[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Consequently, there is a trend towards favoring early surgical intervention in clinical practice.\u003c/p\u003e\u003cp\u003eTo assess the relationship between the timing of surgery and outcomes in IE, it is crucial to accurately determine the date of both diagnosis and surgery. While recording the date of surgery in observational studies is straightforward, accurately capturing the dates of hospitalization, definitive IE diagnosis, and the onset of complications that indicate the need for surgery can be challenging. Similarly, while the modified Duke criteria can confirm a diagnosis of definitive IE, the timing of surgical indication may be delayed by several days until complications such as heart failure symptoms, embolic events, persistent bacteremia, or intracardiac abscesses arise. This time interval between IE diagnosis and the indication for surgery can be further complicated if the patient was initially diagnosed and treated at another hospital before being transferred to a surgical center. Therefore, we conducted a detailed review of the data on symptom onset, initial medical consultation, first hospital treatment, and referral to our center for each patient with IE to comprehensively assess the disease course.\u003c/p\u003e\u003cp\u003eAvoidance of all-cause mortality, disabling stroke, or recurrence of IE at 1 year is a more critical outcome measure for IE surgery compared to in-hospital mortality alone. Therefore, we collected and analyzed detailed data from each group of IE patients. The results indicated no significant differences in composite primary endpoints, such as mortality, incidence of postoperative complications, postoperative cardiac function, and organ dysfunction among the three groups. Additionally, there were no significant differences in postoperative endotracheal intubation duration, ICU length of stay, and total postoperative hospital days. These improvements in in-hospital clinical outcomes did not correspond to an increased risk of surgical mortality or recurrence of IE at 1 year.\u003c/p\u003e\u003cp\u003eStudies have shown that[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] pathogenic microorganisms can be resistant to microbicidal peptides or antimicrobial agents released locally by platelets. The hypercoagulable state associated with nonbacterial thrombotic endocarditis lesions promotes fibrinogen deposition, platelet aggregation, and microbial proliferation, which contributes to infectious redundancy. Thus, while platelets may reflect the patient's physical status to some extent, they are not likely a significant factor in the primary endpoint of the mortality composite. Most cases of infective endocarditis occur in patients with pre-existing heart disease and typically involve the heart valves, with the aortic and mitral valves being the most commonly affected, while the tricuspid and pulmonary valves are less frequently involved. In patients with a longer disease duration, there is often a comorbidity with rheumatic heart disease, leading to differences in mitral regurgitation between groups. This suggests that the management of IE in patients with underlying cardiac disease may be more complex and prolonged. The results also revealed that approximately one-fifth of patients had central nervous system involvement, and systemic embolism occurred in about 10% of patients, including pulmonary, hepatic, splenic, and renal mycotic infarcts, with splenic infarcts accounting for 61% of these cases. Splenic dysfunction is generally less impactful on overall health compared to dysfunction of other organs and thus is not a significant factor in the mortality composite endpoint. It is noteworthy that the differences observed in preoperative treatment duration and in-hospital antibiotic treatment are largely attributable to subgroup variations, with extended preoperative hospital stays often resulting from prolonged antibiotic therapy and the complexity of the condition.\u003c/p\u003e\u003cp\u003eSubsequently, we analyzed the risk factors associated with postoperative mortality by entering all variables into a logistic regression model to identify significant differences between survivors and deceased patients. The analysis revealed that ICU length of stay, postoperative cardiac malfunction, and other organ dysfunction were significant risk factors for composite endpoints such as death. ICU length of stay is known to correlate with disease severity, and postoperative organ dysfunction increases the need for advanced life support. The severity of heart failure has been shown to elevate mortality rates in patients with IE[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Hill et al. suggested that early surgical intervention within 7 days might reduce the incidence of heart failure[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Overall, the primary mortality risk factor for patients remains the state of organ dysfunction. Our 1-year follow-up results corroborate this, with organ dysfunction accounting for 69.23% of death causes.\u003c/p\u003e\u003cp\u003eWe found that the in-hospital and 1-year mortality rates were significantly lower in all three groups compared to previously reported rates[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Several factors may explain the lower mortality observed in our study. First, the proportion of patients with poor prognostic factors, such as moderate-to-severe congestive heart failure and staphylococcal infection (12.2% in this study), was lower than in previous studies[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Second, only 20.5% of patients underwent valve surgery during their initial hospitalization, and 85.5% received effective antibiotics tailored to in-hospital bacterial sensitivity. This suggests that the correct decision-making by the multidisciplinary endocarditis team and the appropriate timing of interventions may be associated with the observed low mortality rates. Third, blood cultures and echocardiography were conducted within 24 hours of hospitalization for all patients with suspected infective endocarditis. The prompt diagnosis based on established guidelines was likely associated with favorable outcomes. Finally, the patient cohort was relatively young, with a mean age close to 50 years, and the rate of reoperation and other mortality-increasing risk factors was low.\u003c/p\u003e\u003cp\u003eHowever, our study has several limitations. First, this study is a retrospective data collection, which limits the design and may introduce biases. Second, the relatively small sample size prevented more detailed stratified analyses, such as propensity score matching, potentially leading to biases related to certain factors. The timing of surgical interventions after hospitalization could have influenced the study results, with patients in poorer clinical conditions possibly experiencing delays or opting against surgery. Nonetheless, all variables were rigorously reviewed to ensure high data quality. Third, preoperative treatment timing, influenced by patient symptoms, may affect prognosis.\u003c/p\u003e\u003cp\u003eOverall, retrospective observational studies, including this one, are susceptible to survivor bias. Early surgical intervention did not increase the risk of death in patients with IE compared to those undergoing late or elective surgery, which may be attributable to the lower incidence of adverse clinical features in the early surgery group. Importantly, 1-year mortality rates were similar across all three groups and were lower than the overall patient mortality rates reported in recent literature. These findings suggest that early cardiac surgery for active infective endocarditis is not contraindicated and can be performed as soon as it is indicated, offering optimal postoperative benefits to patients.\u003c/p\u003e\u003cp\u003eIn conclusion, our team believes that establishing a strong standardised endocarditis team is essential to reduce mortality and improve patient prognosis. Early surgical intervention does not increase the risk of death in patients with IE, nor does it increase the risk of recurrence and reoperation within one year. Therefore, in patients with a clear diagnosis, unstable cardiac function, or risk of recurrent embolism, we recommend early surgical intervention before completing a cycle of antibiotic therapy.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDisclosures.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCRediT authorship contribution statement.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWu Liu: Writing – original draft, Resources, Methodology, Investigation, Data curation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eYongqin Li: Writing – review \u0026amp; editing,Writing – original draft,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHeng Yang: Resources, Methodology, Data curation, Conceptualization.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCongcong Li: Writing – review \u0026amp; editing, Resources,Methodology.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eJinyu Wang: Writing – original draft, Methodology, Investigation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWanqi Lan: Writing – original draft, Software,Resources.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eYanhua Tang: Writing – review \u0026amp; editing, Writing – original draft, Resources, Methodology, Formal analysis, Datacuration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKey Research and Development Program of Jiangxi Province, 20223BBG71010\u003c/p\u003e\n\u003cp\u003eThe Second Affiliated Hospital Of NanChang University Funding Program (No. 2021efyA02)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors are aware of the content of this article, guarantee originality and authenticity, and agree to publish.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData will be made available on request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThese experiments were conducted according to established ethical guidelines, and informed consent obtained from the participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Interest Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there are no conflicts of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCuervo G, Caballero RA, Grau Q, Pujol I, Ardanuy M, Berbel C, Gudiol D, S\u0026aacute;nchez-Salado C, Ruiz-Majoral JC, Sbraga A, Gracia-S\u0026aacute;nchez F, Pe\u0026ntilde;a L, Carratal\u0026agrave; C. J, Twenty-Year Secular Trends in Infective Endocarditis in a Teaching Hospital. Open Forum Infect Dis; 2018 Jul. p. 27.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCahill TJ. P.B., Infective endocarditis. Lancet, 2016 Feb 27.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOtto CM, Bonow NR, Carabello RO, Erwin BA, Gentile JP 3rd, Jneid F, Krieger H, Mack EV, McLeod M, O'Gara C, Rigolin PT, Sundt VH, Thompson TM 3rd, Toly A. C, \u003cem\u003e2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.\u003c/em\u003e Circulation, 2021 Feb 2.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHabib G, Antunes LP, Bongiorni MJ, Casalta MG, Del Zotti JP, Dulgheru F, El Khoury R, Erba G, Iung PA, Miro B, Mulder JM, Plonska-Gosciniak BJ, Price E, Roos-Hesselink S, Snygg-Martin J, Thuny U, Tornos Mas F, Vilacosta P, Zamorano I, ESC Scientific Document Group. JL;, 2015 \u003cem\u003eESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM).\u003c/em\u003e Eur Heart J, 2015 Nov 21.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHorstkotte D, Gutschik FF, Lengyel E, Oto M, Pavie A, Soler-Soler A, Thiene J, von Graevenitz G, Priori A, Garcia SG, Blanc MA, Budaj JJ, Cowie A, Dean M, Deckers V, Fern\u0026aacute;ndez Burgos J, Lekakis E, Lindahl J, Mazzotta B, Morais G, Oto J, Smiseth A, Lekakis OA, Vahanian J, Delahaye A, Parkhomenko F, Filipatos A, Aldershvile G, Vardas J. P; Task Force Members on Infective Endocarditis of the European Society of Cardiology; ESC Committee for Practice Guidelines (CPG); Document Reviewers., \u003cem\u003eGuidelines on prevention, diagnosis and treatment of infective endocarditis executive summary; the task force on infective endocarditis of the European society of cardiology\u003c/em\u003e. Eur Heart J, 2004 Feb.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChirillo F, Rocco SP, Rigoli F, Borsatto R, Pedrocco F, De Leo A, Minniti A, Polesel G, Olivari E. Z., Impact of a multidisciplinary management strategy on the outcome of patients with native valve infective endocarditis. Am J Cardiol, 2013 Oct 15.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFowler VG, Selton-Suty DD, Athan C, Bayer E, Chamis AS, Dahl AL, DiBernardo A, Durante-Mangoni L, Duval E, Fortes X, Fosb\u0026oslash;l CQ, Hannan E, Hasse MM, Hoen B, Karchmer B, Mestres AW, Petti CA, Pizzi CA, Preston MN, Roque SD, Vandenesch A, van der Meer F, van der Vaart JTM, Miro TW. JM, \u003cem\u003eThe 2023 Duke-International Society for Cardiovascular Infectious Diseases Criteria for Infective Endocarditis: Updating the Modified Duke Criteria.\u003c/em\u003e Clin Infect Dis, 2023 Aug 22.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eThuny F, Belliard DSG, Avierinos O, Pergola JF, Rosenberg V, Casalta V, Gouvernet JP, Derumeaux J, Iarussi G, Ambrosi D, Calabr\u0026oacute; P, Riberi R, Collart A, Metras F, Lepidi D, Raoult H, Harle D, Weiller JR, Cohen PJ, Habib A. G, Risk of embolism and death in infective endocarditis: prognostic value of echocardiography: a prospective multicenter study. Circulation, 2005 Jul 5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZoghbi WA, Foster E-SM, Grayburn E, Kraft PA, Levine CD, Nihoyannopoulos RA, Otto P, Quinones CM, Rakowski MA, Stewart H, Waggoner WJ, Weissman A. NJ; American Society of Echocardiography, \u003cem\u003eRecommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography\u003c/em\u003e. J Am Soc Echocardiogr, 2003 Jul.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHill EE, Vanderschueren HM, Claus S, Peetermans P, Herijgers WE. P, \u003cem\u003eOutcome of patients requiring valve surgery during active infective endocarditis. Ann Thorac Surg.\u003c/em\u003e Ann Thorac Surg, 2008 May.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKang DH, Kim KY, Sun SH, Kim BJ, Yun DH, Song SC, Choo JM, Chung SJ, Song CH, Lee JK, Sohn JW. DW, Early surgery versus conventional treatment for infective endocarditis. N Engl J Med, 2012 Jun 28.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAnantha Narayanan M, Kalil MHT, Kanmanthareddy AC, Suri A, Mansour RM, Destache G, Baskaran CJ, Mooss J, Wichman AN, Morrow T, Vivekanandan L. R, Early versus late surgical intervention or medical management for infective endocarditis: a systematic review and meta-analysis. Heart, 2016 Jun 15.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKiefer T, Tribouilloy PL, Cortes C, Casillo C, Chu R, Delahaye V, Durante-Mangoni F, Edathodu E, Falces J, Logar C, Mir\u0026oacute; M, Naber JM, Tripodi C, Murdoch MF, Moreillon DR, Utili P, Wang R. A, Association between valvular surgery and mortality among patients with infective endocarditis complicated by heart failure. JAMA, 2011 Nov 23.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLalani T, Benjamin CC, Lasca DK, Naber O, Fowler C, Corey VG Jr, Chu GR, Fenely VH, Pachirat M, Tan O, Watkin RS, Ionac R, Moreno A, Mestres A, Casab\u0026eacute; CA, Chipigina J, Eisen N, Spelman DP, Delahaye D, Peterson F, Olaison G, Wang L. A, \u003cem\u003eInternational Collaboration on Endocarditis-Prospective Cohort Study (ICE-PCS) Investigators. Analysis of the impact of early surgery on in-hospital mortality of native valve endocarditis: use of propensity score and instrumental variable methods to adjust for treatment-selection bias.\u003c/em\u003e Circulation, 2010 Mar 2.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSupplement Fig. 1: Kaplan-Meier survival analysis of three groups of patients.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Endocarditis, Timing of surgery, Early prognosis","lastPublishedDoi":"10.21203/rs.3.rs-6760790/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6760790/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInfective endocarditis (IE) is a disease caused by the involvement of pathogenic microorganisms in the endocardium, primarily characterized by the formation of growths and progressive valve damage. Despite advances in diagnostic and therapeutic methods, the mortality rate remains high. Conventional treatment typically favors surgery after 4-6 weeks of infection control. Although a series of articles on early surgical treatment have been published in recent years, outcomes for early surgical treatment continue to vary.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBy collecting the clinical data of 166 patients who underwent cardiac surgery for IE between February 1, 2017, and January 31, 2023, we classified the patients into three groups: Group A (radical surgery within 1-7 days after admission), Group B (surgical treatment 8-13 days after admission), and Group C (surgical treatment 14-28 days after admission) according to different treatment strategies. To compare the effects of different times of surgical intervention on the early prognosis of patients, logistic multivariate regression analysis was used to determine the risk factors associated with surgical mortality, and the survival of different groups of patients was compared using Kaplan-Meier survival analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe results showed no significant differences in perioperative reinfarction, endocarditis recurrence, heart failure, or in-hospital mortality among the three treatment groups. However, ICU length of stay (P=0.015, 1.30 [1.05-1.61]), cardiac malfunction (P=0.015, 22.28 [1.82-273.04]), and other organ malfunctions (P=0.007, 29.21 [2.46-346.49]) were identified as risk factors affecting patient mortality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEarly surgical intervention did not increase the risk of death in patients with IE, nor did it increase the risk of recurrence and reoperation within one year. Therefore, we recommend early surgical intervention before completing a cycle of antibiotics in patients with a clear diagnosis, unstable cardiac function, or risk of recurrent embolism.\u003c/p\u003e","manuscriptTitle":"Cardiac surgery timing on the prognosis of patients with infective endocarditis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-17 16:06:08","doi":"10.21203/rs.3.rs-6760790/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-25T17:58:29+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-27T18:13:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-27T16:11:21+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-23T11:17:23+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-23T05:56:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"225291986635346106424578849229192048718","date":"2025-07-22T23:35:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"151075787960489063263588286012086890371","date":"2025-07-21T06:36:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"331280116004250779182619725073345531820","date":"2025-07-20T14:42:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"185476450814396399865843484397513833375","date":"2025-07-17T19:21:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"336312299762524671737607089872575537487","date":"2025-07-17T17:03:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"159438347545086914846077111683550764645","date":"2025-07-17T15:55:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"95738693554884796386607138100807753280","date":"2025-07-16T21:52:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"308584503373664427962773999269621918786","date":"2025-07-16T20:37:28+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-16T18:49:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"15002363155542166998082731341707913327","date":"2025-07-15T15:06:54+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-15T14:46:44+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-28T14:05:52+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-28T14:04:04+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cardiothoracic Surgery","date":"2025-05-27T14:58:53+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9f8dd51b-7b2d-4bd2-8b31-f99dde582031","owner":[],"postedDate":"July 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-29T16:01:58+00:00","versionOfRecord":{"articleIdentity":"rs-6760790","link":"https://doi.org/10.1186/s13019-025-03766-3","journal":{"identity":"journal-of-cardiothoracic-surgery","isVorOnly":false,"title":"Journal of Cardiothoracic Surgery"},"publishedOn":"2025-12-23 15:57:58","publishedOnDateReadable":"December 23rd, 2025"},"versionCreatedAt":"2025-07-17 16:06:08","video":"","vorDoi":"10.1186/s13019-025-03766-3","vorDoiUrl":"https://doi.org/10.1186/s13019-025-03766-3","workflowStages":[]},"version":"v1","identity":"rs-6760790","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6760790","identity":"rs-6760790","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}