What is the cardiothoracic evaluation for multiple vegetations in infective endocarditis?

From the Guidelines

A cardiothoracic surgical evaluation is strongly recommended for patients with multiple vegetations due to endocarditis, particularly when vegetations are large (>10mm), mobile, or involve the mitral or aortic valves. The evaluation should be conducted urgently, ideally within 24-48 hours of diagnosis, as surgical intervention may be necessary to prevent complications such as embolization, heart failure, or uncontrolled infection 1. While awaiting surgical consultation, the patient should receive appropriate antibiotic therapy based on blood culture results, typically including a combination of vancomycin (15-20mg/kg IV every 12 hours) plus ceftriaxone (2g IV daily) for empiric coverage until culture results are available.

Key Considerations

• Definitive therapy should be tailored to the specific pathogen and continue for 4-6 weeks.
• Echocardiography (both transthoracic and transesophageal) should be performed to assess vegetation size, location, and valvular damage 1.
• Surgical intervention is often necessary for vegetations larger than 10mm, persistent bacteremia despite appropriate antibiotics, heart failure symptoms, or evidence of abscess formation.
• Early surgical consultation improves outcomes by allowing for timely valve repair or replacement before catastrophic complications develop, as endocarditis with multiple vegetations carries significant mortality risk if managed with antibiotics alone 1.

Diagnostic Evaluation

• The size and other characteristics of vegetations on echocardiography have been shown to be useful in predicting complications such as peripheral embolization 1.
• Three-dimensional (3D) echocardiography is particularly helpful in defining the size and dimensions of complex lesions 1.
• Change in vegetation size over time is also an important factor, with failure to reduce vegetation size on therapy indicating greater risk for embolic complications 1.

From the Research

Cardiothoracic Evaluation for Multiple Vegetations in Endocarditis

• The presence of multiple vegetations in endocarditis is a serious condition that requires prompt and effective treatment 2, 3, 4, 5, 6.
• The therapeutic goal is to achieve sterilization of the cardiac vegetations, and the choice of antibacterial is dependent upon the susceptibility profile of the causative organism 2, 3, 5.
• Studies have shown that large vegetations (≥1 cm) are associated with a higher risk of mortality, embolic complications, and abscess formation, especially in older patients and those with staphylococcal endocarditis 4.
• The use of aminoglycosides for the treatment of endocarditis has been dramatically reduced over the last 20 years, and should be administered once daily, and no longer than 2 weeks 5.
• The optimal duration of antibacterial treatment is 4 weeks for most native valve endocarditis, and 6 weeks for prosthetic-valve endocarditis 5.
• Residual vegetation after antibiotic treatment for infective endocarditis may have a prognostic impact, particularly if the vegetation is large (> 10 mm) or has increased in size relative to the diagnosis 6.
• The following antibacterial treatments are recommended for endocarditis:
  • Vancomycin or gentamicin for enterococcal endocarditis 2
  • Oxacillin or nafcillin with or without gentamicin for staphylococcal endocarditis in patients with no prosthetic valve 2, 3, 5
  • Vancomycin for methicillin-resistant S. aureus endocarditis 2, 5
  • Cefazolin or ceftriaxone for penicillin-allergic patients with endocarditis caused by viridans streptococci 2