EFFECTS OF CHANGES IN MANAGEMENT OF ACTIVE INFECTIVE ENDOCARDITIS ON OUTCOME IN A 25-YEAR PERIOD

The clinical outcome and long-term follow-up of 130 consecutive patien ts (141 episodes) with active infective endocarditis who were treated between 1966 and 1991 were analyzed. There was a shift toward a higher proportion of referred patients (39 to 78%), patients aged > 60 years . (11 to 41%) and urgent surgical treatment (11 to 44%). Medical treat ment was administered in 98 patients (70%); 30-day mortality was 27%. Surgery was performed in 43 patients (30%), with an operative mortalit y of 26%; 9 of 14 patients (64%) who underwent operation within the fi rst week. of admission died. Patients with severe. heart failure are a t the highest risk for early mortality (relative risk = 21.1; 95% conf idence interval 7.4-60.3). Referred patients were much more often trea ted surgically than were nonreferred patients (48 versus 14%) and had a lower operative mortality (24 vs 30%). Nonreferred patients were mor e often treated medically (86 vs 52%) and with lower mortality (19 vs 39%). The total follow-up time was 730 patient years; only 1 patient w as considered lost to follow-up. The overall cumulative 5-year and 10- year survival after hospital discharge for patients after urgent surge ry were 84 +/- 7% and 53 +/- 7%, respectively, and for those after med ical treatment 84 +/- 5% and 77 +/- 6%, respectively., The probability of remaining free of late events (recurrent endocarditis, late valve replacement or death) during 5 and 10 years for patients after urgent surgery was 84 +/- 7% and 53 +/- 15%, respectively, and for those afte r medical treatment 59 6% and 40 +/- 7%, respectively. In the first ye ar after hospital discharge, the incidence of late events was high, es pecially in patients who received only medical treatment. Although urg ent surgery has improved the outlook for some patient groups, early mo rtality did not decrease significantly owing to a shift toward more co mpromised cases.