Surgical Versus Non-surgical Management of Acute and Subacute Infective Endocarditis in Patients With Rheumatic Heart Disease During the COVID-19 Pandemic: A Propensity-Matched Analysis

Background: Infective endocarditis remains a life-threatening condition requiring timely medical and surgical management. The COVID-19 pandemic posed unprecedented challenges to healthcare delivery, yet the outcomes of surgical versus conservative management among patients with infective endocarditis and underlying rheumatic heart disease during this period remain poorly defined. Objective: This study aims to compare 30-day outcomes following surgical versus conservative management among adult patients with acute and subacute infective endocarditis in the setting of rheumatic heart disease during the COVID-19 pandemic. Methods: Adult patients (≥18 years) admitted with acute or subacute infective endocarditis and underlying rheumatic heart disease between January 20, 2020, and July 20, 2021, were identified from the TriNetX COVID-19 Research Network. Patients with laboratory-confirmed COVID-19 infection were excluded. Patients undergoing valve surgery within one month of the index admission were compared with those managed conservatively. One-to-one propensity score matching was performed using demographic characteristics, comorbidities, laboratory values, intensive care utilization, left ventricular ejection fraction, and antibiotic therapy. The primary endpoint was 30-day all-cause mortality. Secondary outcomes included stroke, respiratory failure, pulmonary embolism, deep vein thrombosis, splenic abscess, lung abscess, and cardiac arrhythmias. Results: A total of 573 patients met the inclusion criteria, including 45 patients who underwent surgery and 528 patients managed conservatively. After propensity score matching, 36 patients remained in each cohort with well-balanced baseline characteristics. Surgical management was associated with significantly lower 30-day mortality compared with conservative treatment (97.1% vs. 78.1% survival; p=0.017). Patients undergoing surgery also had lower risks of stroke (risk difference (RD) 50.0%, p<0.001), splenic abscess (RD 29.4%, p=0.001), lung abscess (RD 29.4%, p=0.001), and pulmonary embolism (RD 45.5%, p=0.001). Respiratory failure occurred more frequently in the surgical cohort (RD −47.6%, p=0.001), while rates of deep vein thrombosis and cardiac arrhythmias were similar between groups. Conclusions: Among adults with acute and subacute infective endocarditis and underlying rheumatic heart disease treated during the COVID-19 pandemic, surgical management was associated with improved 30-day survival and lower rates of major embolic and infective complications compared with conservative management. These findings support the continued role of timely surgical intervention in appropriately selected patients, even during periods of significant healthcare system strain.