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and you guys deal with this a Hampton as a CT equivalence and cardiothoracic surgery. And today the purpose is to discuss relevant of it here in and cardiac surgery, which is early surgery versus conventional treatment for infective endocarditis. Do we have an answer? And this is a narrative review by a group of, uh, surgeons. And, uh, we'll be looking at that today, So that's an outline. Well, we're looking at the overview is methodology of the research the prime minister's That can be outcomes and results discussion and then conclusion. So that's a well overview infective. Endocarditis is something I'm sure we all know, and it's a life threatening information of the inner lining of the touching. This end valves and mortality a year is about 30%. The problem with infected in the varieties is within the last two decades, and the incidents of infected acolytes have seemed to double from 25 to 50. And we all know that the infecting myocarditis is diagnosis in the modified criteria, and this is quite relevant because of the of the articles and then the different contrary research that have been done. So all the research articles in important varieties must follow. The fact that diagnosis were confirmed were confirmed. All different diagnoses were made using the modified the criteria, and the reason for this discussion today is because of the discrepancies in the surgical management and impertinent Politis. So the question is, what is the most appropriate strategy and timing for surgery in infected with hepatitis for many years, it's been well demonstrated in different randomized control trials that antibiotic treatment is the backbone or the cornerstone of treatment for infected in the varieties. However, the different surgical groups or the different societies with the American Heart Association and the European Society of Cardiology have contrary evidence or contrary guidelines with regard to the surgical management of the effective and the varieties. Whilst the European Society of Cardiology describes three levels of management, the American Heart Association just have 111 guideline, and this is fooling the confusion. So, uh, and worst among it all is the father that Parral to 2015. When the European states of cardiology re released their guidelines, which was another five division, there was not a single randomized control trial in the surgical manager names of infecting on the priorities and that is the reason for why we're having this discussion today. So, like I said, over the last 20 years there's been seven randomized control trials where public, which I published concerning antibiotic treatment and this can be found on public. And there's only one RCT, which is called the East Trial, which was done in in Korea in South Korea by Kanga, uh, colleagues and what they were looking and what they were looking at was they were comparing early surgery versus conventional treatment for effective and the diabetes. So with with the definition of early surgery, they were looking at surgery within 48 hours. However, like I was saying earlier, this is where the discrepancies come in between the European guidelines and, uh, American guidelines. And in the past, all the researchers that have been done in the surgical management of endocarditis have been, um, observational studies, uh, using propensity, matched analysis, and therefore it has not really generated a concrete and guideline or concrete pathway of management. So one group, which is the European, will say early surgeries within seven days for American guideline. This is that management of infective endocarditis, uh, other than being under than having an emergency surgery. The only thing you could do is wait till the period or do it throughout the period of admission. So there is no clear couple points. And this is alarming because of the complications of infective endocarditis on the surgical point of view, which is mostly the risk of embolism, which has been reported in many papers as up to about 15 to 30% and then the risk of severe congestive heart failure. Our So this East trial was the breakthrough for the scratch, for for the management or the discussion, and this is how they developed their methodology. So the methodology was the the invited or used eight patient's who were 18 years and above, who had definite diagnosis, using the modified criteria as having infected with hepatitis and these 130 for patient's, where patient's that were randomly assigned and they had the inclusion criteria, whether they have to be patient with left sided in person in the colitis, patient with severe valve disease and patient with large vegetations large vegetations. And then they randomized them into the conventional treatment, which is treatment weight and you give infected. You give antibiotics until, uh, whenever possible to have surgery, uh, reason being that the risk of operating on an inflamed add valve and and and evolve with a lot of, uh, officials, uh, effective organisms had a risk to the patient also, and it it made repair in surgery difficult. So prevention treatment is just give you antibiotics til if the patient never becomes well. And there's persistent bacteremia persistent services, persistent vegetation, then we'll go for surgery. And this. This had a lot of mortality issue and then early surgery in this guy's group, where groups where, where you have your surgery within 48 hours you have a model, you have a confirmed infected keratitis. Then they randomized you into the early surgery group when they when they recruited 130 for Patient's 44 were excluded. And this way, because 26 had to go, uh, into emergency surgery and 18 did not have the the criteria. The inclusion criteria, which was a severe bout disease or a vegetation more than one centimeters, and therefore these guys were had their, uh, usual treatment with antibiotics without any surgical involvement. So when 44 fell out of the group 104 we had 90 people for assessment. The 90 pick the 90 Group 90 patient's too sorry. The 19th or 2 14 were excluded because I've had major stroke five when four medical conditions and for the declined to participate, eventually leaving the number 2 76 people. And this is one of the limitations of the study because was under under powered by the smaller number. So eventually, 76 people were randomized into two groups. One group being 37 people for early surgery and another group was 39. Patient with the conventional treatment and their premier and secondary accidents way in hospital, there's, um, or clinical embolic events that occurred within six weeks after RANDOMIZATION and the secondary endpoint. We were looking at six months of flu out, which included all cause mortality or all cause death from in equals, including embolic and recurrence of the effective in Ecuador itis sorry and repeat what to buy hospitalization due to the infection and this where the resource or the outcome So the analyzed, the in the groups were all based on intention to treat, so there was no crossovers, and they analyzed, uh the data using the Kaplan Mayer method, which is a long rank and test and used to tailed P value of 0.5%. And these were the findings, the primary and secondary outcomes. So what they found was that what they found out was that all the patient's assigned to the early surgery group and I went by surgery within 48 hours after RANDOMIZATION, whereas the 30 whereas 30 patient's in the Conventional Treat Statement group, underwent surgery during the initial specialization or during the fuller period and then the primary endpoint or killing one patient in the early surgery, which was 3% and then the primary endpoint in the conventional treatment occurred in nine patient, which which was 2030% of the P value of 0.1, which was very significant in terms of in hospital death in the primary endpoint. Within the first six weeks, we had one patient in each group which was not really statistically significant, and then the other issue, which is the other competition factor, which is to be looked at in the important practice. The other premier point was the risk of embolism or if there was an embolic event within the six weeks. And then they realized that with all the patient that had early surgery, none none had a recorded accidental is, um, with all the patient's in the conventional group, you realize that eight in Twitter had, uh, an embolic event within the system. Weeks and months were seen in the cerebral and which this is quite comparable with the previous of this observational studies that have shown that there's a high risk embolism impression that had delayed, uh, surgical interventions. So at their secondary point for within six months, what they realized was that all cause mortality, any debt resulting we're living, which contribute to 28%. And this was very highly significant. So just one the one patient who was seen within the first primary endpoint and then still assessment put out debt. Um, sorry. In the breakdowns of death, where two and to uh, the second one point assistant was two decades, eight embolic events and then one recurrence of the infected myocarditis and there was no recurrence of infected with hepatitis were embolic events in the early surgery. So to look at the limitations of this study, this. This study was, uh, the East Trial, which is the trial which was looked upon, uh, in the narrative review, which I, which was posted on the page, is the first victory of any random ization done, uh, to look at the benefit of having an early surgical intervention in the patient with the 30 enthesitis or having and what is the conventional treatment plan or conventional treatment matter? The the good thing is about this study is that it is a randomized control trial. Uh, they tried to make it two centers. However, this was, uh they did not analyze data from the two centers because they had low participation at the end. Uh, which underpowered the study. And then secondly, the the second center had only three patient's eventually. So they had a joint announcer, the data, and therefore could not tell whether low volume centers uh, what experience? The same level of, uh, data. I will explain the same level of accuracy with the information. And then the second thing was that because of the low sample size which has already been mentioned, uh, it's a bit difficult to project entirely the the the real significance across the force values. So what's the future of the ineffectively crisis plan? So after this trial, uh, there is another trial ongoing. The US, which is to end in April 2024 their first primary endpoint Will would results will come out next year in April before their final endpoint in April 2024. And this is based on using a population data of using parts parts of about 216 Patient's, uh, in about 19 centers. So this will be the biggest and the largest study in randomizing patient into, uh, conventional treatment in the early surgery. And they are looking at early surgery within 72 hours and the risk of embolism and within the first primary endpoints and then the all cause mortality at the end. So in conclusion, uh, with this, uh, narrative review that we saw, we've we've established that early surgery is as compared to the professional treatment is significantly reduced the composite endpoint of death from any cause for embolic events by effectively reducing the risk of systemic embolism among patients with infected in activities and large vegetation. And this brings me to the end of the preservation. Thank you. If there are any questions, All contributions to the article about message. Thank you very much. Um, summer for, um, that presentation, Um, really covered everything about representation in, um, in a really good time. Thank you very much. Um, if we have any questions now, um, we'll just take questions. Um, I realized that, um, sometimes it, uh, turn out for the journal clubs a little bit low because because of the catch up content, you know, I'm looking from the back end. Um, you know a lot. A lot more people watch the videos. You know, after the meeting. Um, you know, So I guess that's what's with the effects in the tunnel. But if we have any questions now from anybody here, um, we'll just take questions. All right, Francis. Thank you. I just wait a few minutes for any question. Yeah. Okay. So I think if there are no questions from now, I could just leave my email in the chat. And just in case if anyone would want to reach me after one another time and any question that I'll be happy to assist Yes, that that would be a good summer because the chat box for medal is sort of like a live chat box. So, um, anybody who watches the video later would also be able to see the messages. Um, so if you just drop your email there, um, and then anybody who has any questions, you can send you the email. And I'm sure some will be more than happy to, um, to answer those questions for you. Um um, Thank you very much, Sam. Or thanks very much. Everyone who has attended now, um, and those who would still attend later and, you know, watch the catch up content. Um, uh, we've gotten some really good feedback from this journal club, so I know that it's, um it's helping a number of people. Um, so thank you very much, everybody. Um So we'll see you next month. Um, but before then, um, on the WhatsApp group will tell you what we're doing. Um, and, um, the the journal be present and will be presenting also, Um, all right, so thanks very much, everybody. Yeah. Bye bye.