From the Guidelines
Surgery in infective endocarditis is indicated in scenarios where there is heart failure, uncontrolled infection, prevention of embolism, or valve dysfunction causing hemodynamic instability, as outlined in the 2015 ESC guidelines 1. The primary indications for surgery include:
- Heart failure due to valve dysfunction, such as severe acute regurgitation, obstruction, or fistula causing refractory pulmonary edema or cardiogenic shock
- Uncontrolled infection despite appropriate antibiotic therapy, including locally uncontrolled infection, infection caused by fungi or multiresistant organisms, or persisting positive blood cultures
- Prevention of embolic events, such as persistent vegetations >10 mm after one or more embolic episodes despite appropriate antibiotic therapy
- Valve dysfunction causing hemodynamic instability, such as severe valvular regurgitation or obstruction The timing of surgery is crucial, with emergency surgery needed for severe heart failure or septic shock, urgent surgery (within days) for uncontrolled infection or prevention of embolism, and elective surgery for stable patients requiring valve replacement 1. It is essential to balance the benefits of surgery against the risks, particularly in patients with comorbidities, and to involve a multidisciplinary team including cardiologists, cardiac surgeons, and infectious disease specialists in the decision-making process. The 2015 ESC guidelines provide a comprehensive outline of the indications and timing of surgery in left-sided valve infective endocarditis, and should be consulted for specific guidance on the management of individual patients 1.
From the Research
Indications for Surgery in Infective Endocarditis
The indications for surgery in infective endocarditis (IE) include:
- Heart failure, most commonly from acute valvular insufficiency 2
- Uncontrolled and persistent infection 2, 3
- Recurrent embolic events 2, 3
- Refractory heart failure due to valvular lesions, intracardiac fistulas, and high-grade cardiac conduction abnormalities caused by septal abscesses 4
- Detection of root abscesses or mycotic aneurysms using transoesophageal echocardiography 4
- Systemic embolisms with persistent, large, and mobile vegetative lesions 4
Timing of Surgery
The optimal timing of surgery in IE depends on various factors, including:
- Haemodynamic tolerance of the patient 4
- Severity of anatomical lesions 4
- Type of endocarditis (native or prosthetic valve) 4
- Type of surgery 4
- Bacterial aetiologies 4
- Early surgery can avoid death and severe complications, but its benefits must be weighed against operative risks and long-term consequences 3
High-Risk Patients
Surgical intervention is generally considered indicated in high-risk patients who have developed severe complications, such as: