When is surgery recommended for acute bacterial endocarditis?

From the Guidelines

Surgery is recommended for acute bacterial endocarditis in patients with severe valve regurgitation, uncontrolled infection, recurrent embolic events, or complications like abscess formation, as indicated by the 2015 ESC guidelines 1. The indications for surgery in acute bacterial endocarditis can be summarized as follows:

• Heart failure due to valve damage
• Uncontrolled infection despite appropriate antibiotic therapy
• Recurrent embolic events
• Complications like abscess formation, heart block, or valve perforation
• Fungal endocarditis or prosthetic valve endocarditis with persistent bacteremia or valve dysfunction
• Large vegetations (>10mm) with embolic potential, especially on the mitral valve

The timing of surgery is crucial, with early intervention (within 48 hours) recommended for patients with severe valve regurgitation causing heart failure, as stated in the 2015 ESC guidelines 1. The decision for surgery should be made by a multidisciplinary team considering the patient's overall condition, comorbidities, and surgical risk, as emphasized in the 2008 ACC/AHA guidelines 1. Even during active infection, surgery may be necessary as the benefits of removing infected tissue and restoring cardiac function often outweigh the risks of operating during bacteremia, as noted in the 2015 ESC guidelines 1.

Some key points to consider when deciding on surgery for acute bacterial endocarditis include:

• The presence of severe valve regurgitation or obstruction causing symptoms of heart failure or echocardiographic signs of poor hemodynamic tolerance 1
• Locally uncontrolled infection, such as abscess, false aneurysm, fistula, or enlarging vegetation 1
• Infection caused by fungi or multiresistant organisms 1
• Persistent vegetations >10 mm after one or more embolic episodes despite appropriate antibiotic therapy 1

From the Research

Indications for Surgery in Acute Bacterial Endocarditis

The decision to perform surgery in acute bacterial endocarditis is based on several factors, including the presence of heart failure, uncontrolled infection, and prevention of embolism. The following are some of the indications for surgery:

• Heart failure, particularly if it is severe and unresponsive to medical therapy 2, 3, 4, 5
• Uncontrolled infection, despite appropriate antibiotic therapy 2, 3, 4, 5
• Large vegetations (>15-20 mm) or mobile vegetations, which increase the risk of embolism 2, 6
• Severe valvular regurgitation or obstruction 2, 3
• Refractory acute pulmonary edema or cardiogenic shock 2
• Presence of paravalvular lesions or advanced atrioventricular block 2
• Persistence of positive cultures for more than 48-72 hours despite antibiotic therapy 2
• Isolation of certain microorganisms, such as fungi or multi-resistant organisms in native IE, or staphylococci or gram-negative pathogens in prosthesis IE 2

Timing of Surgery

The timing of surgery is also an important consideration:

• Emergent surgery (<48 hours) may be indicated in patients with severe symptoms, such as heart failure or uncontrolled infection 2, 5
• Early surgery (within a few days) may be indicated in patients with large vegetations, severe valvular disease, or uncontrolled infection 2, 5
• Delayed surgery (2-4 weeks) may be indicated in patients with large cerebral infarction or intracerebral hemorrhage, to reduce the risk of neurological deterioration and perioperative cerebral bleeding 2, 5
• A multidisciplinary approach, involving cardiologists, cardiac surgeons, and infectious disease specialists, is recommended to determine the optimal timing of surgery 2, 5