Surgery in current therapy for infective endocarditis

Stuart J Head1, M Mostafa Mokhles1, Ruben LJ Osnabrugge1,2, Ad JJC Bogers1, A Pieter Kappetein11Department of Cardio-Thoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands; 2Department of Epidemiology, Erasmus University Medical Center, Rotterdam, The NetherlandsAbstract: The introduction of the Duke criteria and transesophageal echocardiography has improved early recognition of infective endocarditis but patients are still at high risk for severe morbidity or death. Whether an exclusively antibiotic regimen is superior to surgical intervention is subject to ongoing debate. Current guidelines indicate when surgery is the preferred treatment, but decisions are often based on physician preferences. Surgery has shown to decrease the risk of short-term mortality in patients who present with specific symptoms or microorganisms; nevertheless even then it often remains unclear when surgery should be performed. In this review we i) systematically reviewed the current literature comparing medical to surgical therapy to evaluate if surgery is the preferred option, ii) performed a meta-analysis of studies reporting propensity matched analyses, and iii), briefly summarized the current indications for surgery.Keywords: endocarditis, surgery, antibiotics, review, meta-analysis, propensity analysis, mortality, complication

Cost-effectiveness of transcatheter valvular interventions: economic challenges

The unsustainable trend of rising healthcare costs necessitates difficult allocation decisions by governments, policymakers, and physicians. Consequently, recent advances in transcatheter valve therapies require not only clinical evaluation, but also careful economic evaluation. Under current indications, each year there are nearly 18,000 new candidates for transcatheter aortic valve implantation (TAVI) in European countries and an additional 9,200 in North America, with an estimated cost of more than $2 billion per year. Nonetheless, when compared with standard medical therapy for severe aortic stenosis (AS), TAVI leads to gains in life expectancy at an incremental cost that is acceptable by most Western standards. On the other hand, for high-risk (but operable) patients with severe AS, TAVI provides no proven survival advantage and only a transient quality of life benefit compared with surgical aortic valve replacement (SAVR). Thus, for these patients, the cost-effectiveness of TAVI compared with SAVR hinges on the magnitude and duration of the quality of life benefit as well as the relative cost of both procedures. Current data suggest that, for patients who are eligible for transfemoral access, TAVI is economically attractive (or even economically dominant) compared with high-risk SAVR. However, the cost-effectiveness of TAVI for patients who are not suitable for a transfemoral approach appears to be less favourable. Transcatheter mitral valve repair is in an earlier stage of clinical implementation than TAVI. As the evidence for this procedure accumulates, more formal economic analysis should be feasible