From the Guidelines
Surgery for infective endocarditis is indicated for left-sided endocarditis in cases of heart failure, uncontrolled infection, prevention of embolic events with large vegetations, and abscess formation, whereas for right-sided endocarditis, surgery is generally reserved for persistent infection, recurrent septic pulmonary emboli, vegetations larger than 20mm, or severe tricuspid regurgitation causing right heart failure. The indications for surgery in left-sided versus right-sided infective endocarditis differ due to the distinct hemodynamic consequences and embolic risks associated with each 1.
Left-Sided Endocarditis
For left-sided endocarditis, affecting the mitral and aortic valves, surgery is often urgent due to the high risk of systemic complications. The main indications include:
- Heart failure due to valve dysfunction
- Uncontrolled infection despite antibiotics
- Prevention of embolic events with large vegetations (>10mm)
- Abscess formation
These conditions necessitate urgent surgical intervention to prevent further complications and improve patient outcomes 1.
Right-Sided Endocarditis
In contrast, right-sided endocarditis, primarily affecting the tricuspid valve, often responds better to antibiotics alone, particularly in intravenous drug users. Surgery is generally less common and reserved for:
- Persistent infection despite appropriate antibiotics (usually after 7-14 days of treatment)
- Recurrent septic pulmonary emboli
- Vegetations larger than 20mm
- Severe tricuspid regurgitation causing right heart failure
The decision for surgical intervention in right-sided endocarditis should be made on a case-by-case basis, considering the patient's overall condition and response to antibiotic therapy 1.
Timing of Surgery
The timing of surgery is critical in both left-sided and right-sided endocarditis. Emergency intervention is needed for cardiogenic shock or acute valve perforation, while urgent surgery (within days) is recommended for heart failure or uncontrolled infection 1.
Multispecialty Approach
Decisions about the timing of surgical intervention should be made by a multispecialty Heart Valve Team of cardiology, cardiothoracic surgery, and infectious disease specialists to ensure the best possible outcomes for patients with infective endocarditis 1.
From the Research
Indications for Surgery in Infective Endocarditis
The indications for surgery in infective endocarditis (IE) are based on various factors, including the presence of heart failure, uncontrolled or persistent infection, and recurrent embolic events 2.
- Heart failure is the most common indication for surgery in IE patients, often resulting from acute valvular insufficiency 2.
- Uncontrolled or persistent infection, despite appropriate antimicrobial therapy, is another major indication for surgical intervention 2, 3.
- Recurrent embolic events, particularly in patients with large vegetations, are also a significant indication for surgery 4, 3.
Left-Sided vs. Right-Sided Infective Endocarditis
While the provided studies do not specifically differentiate between left-sided and right-sided IE in terms of surgical indications, they do emphasize the importance of early surgical intervention in complicated IE cases, including those with heart failure, uncontrolled infection, and embolic events 4, 5, 3.
- Left-sided IE is more commonly associated with embolic events and heart failure, which may require earlier surgical intervention 4, 5.
- The decision to operate on right-sided IE is often based on the presence of complications, such as recurrent emboli, heart failure, or uncontrolled infection 2, 6.
Timing of Surgery
The timing of surgery in IE is complex and depends on various factors, including the patient's condition, the presence of complications, and the risk of surgery 5, 3.