From the Guidelines
Surgery is indicated for mitral valve endocarditis with a 1cm vegetation in cases of heart failure, uncontrolled infection, or prevention of embolism, as outlined in the 2015 ESC guidelines 1. The indications for surgery in mitral valve endocarditis with a 1cm vegetation include:
- Heart failure due to severe acute regurgitation, obstruction, or fistula causing refractory pulmonary edema or cardiogenic shock, which requires emergency surgery 1
- Uncontrolled infection, such as locally uncontrolled infection (abscess, false aneurysm, fistula, enlarging vegetation), which requires urgent surgery 1
- Prevention of embolism, such as persistent vegetations >10 mm after one or more embolic episodes despite appropriate antibiotic therapy, which requires urgent surgery 1 The 1cm vegetation size itself is not an absolute indication for surgery, but it carries an increased risk of systemic embolization, especially to the brain, and may require surgery if it is mobile or associated with other high-risk features 1. Additional indications for surgery include:
- Severe valvular regurgitation causing hemodynamic instability
- Perivalvular extension of infection
- Infection with resistant organisms The timing of surgery is crucial, with emergent surgery needed for severe heart failure or uncontrolled infection, and early surgery (within days) appropriate for large mobile vegetations with embolic risk 1. The surgical approach typically involves valve repair when possible or replacement with either mechanical or biological prostheses, with the choice depending on patient age, comorbidities, and anticoagulation considerations 1. Complete debridement of infected tissue is essential during surgery to prevent recurrence, and patients require 4-6 weeks of appropriate antibiotics regardless of surgical intervention, with the regimen tailored to the causative organism 1.
From the Research
Indications for Surgery in Mitral Valve Endocarditis
The decision to perform surgery in mitral valve endocarditis depends on several factors, including the size of the vegetation, the presence of complications, and the patient's overall health.
- Surgery is often recommended for patients with large mobile vegetations, as they are at high risk for embolism 2.
- A vegetation size of 1cm or larger is considered a high risk for embolism, and surgery may be indicated in these cases 2.
- Other indications for surgery include:
- Intractable heart failure
- Persistent uncontrollable infection
- Peripheral embolism
- Prosthetic valve endocarditis 3
- The timing of surgical intervention is crucial, and optimal timing can result in reduced early and late mortality 3.
- Mitral valve repair is a viable option for patients with mitral regurgitation due to active infective endocarditis, especially if the infection is limited to the leaflet 4.
- However, the feasibility of valve repair depends on the extent of tissue destruction, and large defects or involvement of the aortic valve may necessitate valve replacement 3.
Considerations for Surgery
- The risk of embolization increases with increasing vegetation size, particularly in mitral endocarditis and staphylococcal endocarditis 2.
- An increase in vegetation size despite antimicrobial treatment may predict later embolism 2.
- Early surgery may be reasonable for patients with small non-hemorrhagic infarction 5.
- The decision to perform surgery should be made on a case-by-case basis, taking into account the individual patient's risk factors and overall health.