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A Propensity Analysis

Holenarasipur R. Vikram, MD; Joan Buenconsejo, MPH; Rodrigo Hasbun, MD; Vincent J. Quagliarello, MD

JAMA. 2003;290:3207-3214.

Context  Complicated, left-sided native valve endocarditis causes significant morbidity and mortality in adults. The presumed benefits of valve surgery remain unproven due to lack of randomized controlled trials.

Objective  To determine whether valve surgery is associated with reduced mortality in adults with complicated, left-sided native valve endocarditis.

Design and Setting  Retrospective, observational cohort study conducted from January 1990 to January 2000 at 7 Connecticut hospitals. Propensity analyses were used to control for bias in treatment assignment and prognostic imbalances.

Patients  Of the 513 adults with complicated, left-sided native valve endocarditis, 230 (45%) underwent valve surgery and 283 (55%) received medical therapy alone.

Main Outcome Measure  All-cause mortality at 6 months after baseline.

Results  In the 6-month period after baseline, 131 patients (26%) died. In unadjusted analyses, valve surgery was associated with reduced mortality (16% vs 33%; hazard ratio [HR], 0.43; 95% confidence interval [CI], 0.29-0.63; P<.001). After adjustment for baseline variables associated with mortality (including hospital site, comorbidity, congestive heart failure, microbial etiology, immunocompromised state, abnormal mental status, and refractory infection), valve surgery remained associated with reduced mortality (adjusted HR, 0.35; 95% CI, 0.23-0.54; P<.02). In further analyses of 218 patients matched by propensity scores, valve surgery remained associated with reduced mortality (15% vs 28%; HR, 0.45; 95% CI, 0.23-0.86; P = .01). After additional adjustment for variables that contribute to heterogeneity and confounding within the propensity-matched group, surgical therapy remained significantly associated with a lower mortality (HR, 0.40; 95% CI, 0.18-0.91; P = .03). In this propensity-matched group, patients with moderate to severe congestive heart failure showed the greatest reduction in mortality with valve surgery (14% vs 51%; HR, 0.22; 95% CI, 0.09-0.53; P = .001).

Conclusions  Valve surgery for patients with complicated, left-sided native valve endocarditis was independently associated with reduced 6-month mortality after adjustment for both baseline variables associated with the propensity to undergo valve surgery and baseline variables associated with mortality. The reduced mortality was particularly evident among patients with moderate to severe congestive heart failure.

Author Affiliations: Department of Internal Medicine, Yale University School of Medicine, New Haven, Conn. Dr Vikram is now with Infectious Disease Section, Hospital of St Raphael, New Haven, Conn. Ms Buenconsejo is now with Yale University School of Epidemiology and Public Health, New Haven, Conn. Dr Hasbun is now with Infectious Disease Section, Tulane University School of Medicine, New Orleans, La.

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