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In Reply We agree with Baxi and colleagues that it is important to consider the inherent limitations of this observational study even with our efforts to reduce treatment selection and survival biases. Referral bias affecting eligibility for the International Collaboration on Endocarditis (ICE) prospective registry may influence our findings because ICE participating sites are tertiary care centers and patients are largely transferred for complications related to endocarditis requiring surgery.1 Unfortunately, the ICE–Prospective Cohort Study registry did not capture information on patients who are not transferred or receive surgery prior to transfer. Baxi and Liu correctly emphasize that these patients represent a subgroup with urgent surgical needs and for whom earlier surgery could influence survival. However, surgical urgency was one of the strongest variables associated with higher operative mortality in the Society of Thoracic Surgery database.2
Lalani T, Wang A. Mortality and Timing of Surgery for Prosthetic Valve Endocarditis—Reply. JAMA Intern Med. 2014;174(3):480-481. doi:10.1001/jamainternmed.2013.13684