In which patients with endocarditis is surgery required for optimal outcome, considering factors such as large (>10-mm) hypermobile vegetation, prior systemic embolus, significant valve dysfunction, persistent bacteremia despite optimal antimicrobial therapy, very large (>30-mm) vegetation, or poorly responsive endocarditis due to highly antibiotic-resistant organisms?

From the Guidelines

Surgery is required for optimal outcome in patients with endocarditis who have large (>10-mm) hypermobile vegetation, particularly with prior systemic embolus, significant valve dysfunction, or very large (>30-mm) vegetation, as well as those with poorly responsive endocarditis due to highly antibiotic-resistant organisms. This recommendation is based on the most recent and highest quality study, which provides guidelines for the management of infective endocarditis 1. The study outlines specific indications for surgery, including heart failure, uncontrolled infection, and prevention of embolism. Patients with large vegetations, prior embolic events, and significant valve dysfunction are at high risk of complications, including further embolization and heart failure.

Key Indications for Surgery

• Heart failure due to severe acute regurgitation, obstruction, or fistula
• Uncontrolled infection, including locally uncontrolled infection or infection caused by fungi or multiresistant organisms
• Prevention of embolism, particularly in patients with persistent vegetations >10 mm after one or more embolic episodes
• Very large vegetations (>30 mm)
• Poorly responsive endocarditis due to highly antibiotic-resistant organisms The study also emphasizes the importance of a multispecialty team approach in making decisions about timing of surgical intervention 1. Early surgical intervention can remove infected tissue, repair or replace damaged valves, and prevent life-threatening complications.

Timing of Surgery

• Emergency surgery: within 24 hours for patients with heart failure or uncontrolled infection
• Urgent surgery: within a few days for patients with persistent vegetations or significant valve dysfunction
• Elective surgery: after at least 1-2 weeks of antibiotic therapy for patients with stable disease.

From the Research

Patients Requiring Surgery for Optimal Outcome

Surgery is required for optimal outcome in patients with endocarditis who have certain characteristics, including:

• Large (>10-mm) hypermobile vegetation 2
• Prior systemic embolus 3, 4, 5
• Significant valve dysfunction 3, 6, 4, 5
• Persistent bacteremia despite optimal antimicrobial therapy 3, 6, 4, 5
• Very large (>30-mm) vegetation 2
• Poorly responsive endocarditis due to highly antibiotic-resistant organisms 3, 6, 4, 5

Indications for Surgery

The following are indications for surgery in patients with endocarditis:

• Heart failure by acute valvular insufficiency refractory to medical treatment 6, 4, 5
• Infections by microorganisms with low response to antibiotics 6, 5
• Paravalvular abscess or cardiac fistulas 6, 4
• Prevention of cerebral embolism when large vegetations are present 6, 2, 5
• Prosthetic valve endocarditis with prosthesis dysfunction, including significant perivalvular leaks or obstruction 6

Timing of Surgery

The optimal timing of surgery depends on various factors, including:

• Haemodynamic tolerance of the patient 3, 4
• Severity of anatomical lesions 3, 4
• Nature of surgery 3, 4
• Type of endocarditis (native or prosthetic valve) 3, 4
• Causal organism 3, 4
• Early surgery (<2 weeks from diagnosis) is associated with better survival compared to delayed surgery 2