From the Guidelines
Surgery is required for optimal outcome in patients with endocarditis who have large (>10-mm) hypermobile vegetation, persistent bacteremia despite optimal antimicrobial therapy, very large (>30-mm) vegetation, or poorly responsive endocarditis due to highly antibiotic-resistant microorganisms. This recommendation is based on the most recent and highest quality study, which provides clear guidelines for the management of infective endocarditis 1. The study highlights the importance of surgery in patients with large vegetations, particularly those exceeding 10mm, as they significantly increase the likelihood of systemic embolization.
Key Indications for Surgery
- Heart failure due to severe acute regurgitation, obstruction, or fistula causing refractory pulmonary edema or cardiogenic shock
- Uncontrolled infection, including locally uncontrolled infection, infection caused by fungi or multiresistant organisms, and persisting positive blood cultures despite appropriate antibiotic therapy
- Prevention of embolism, including patients with persistent vegetations >10 mm after one or more embolic episodes despite appropriate antibiotic therapy
- Very large vegetations (>30 mm) or isolated large vegetations (>15 mm) with no other indication for surgery
Timing of Surgery
The timing of surgery is crucial, with emergency surgery recommended for patients with heart failure due to severe acute regurgitation, obstruction, or fistula causing refractory pulmonary edema or cardiogenic shock 1. Urgent surgery is recommended for patients with uncontrolled infection, prevention of embolism, and very large vegetations.
Benefits of Surgery
Surgery has been shown to reduce mortality and improve long-term outcomes compared to antimicrobial therapy alone 1. The surgery typically involves vegetation removal and valve repair or replacement, which eliminates the source of emboli and restores proper valve function.
Considerations
It is essential to consider the individual patient's risk-benefit analysis, taking into account the size and mobility of the vegetation, history of previous embolic events, and significant valve dysfunction 1. A multispecialty Heart Valve Team of cardiology, cardiothoracic surgery, and infectious disease specialists should make decisions about the timing of surgical intervention 1.
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, 3
- Persistent bacteremia despite optimal antimicrobial therapy 2, 3, 4
- Very large (>30-mm) vegetation 3
- Poorly responsive endocarditis due to highly antibiotic-resistant microorganisms 2, 3
Indications for Surgery
The indications for surgery in patients with endocarditis include:
- Heart failure, most commonly from acute valvular insufficiency 3
- Uncontrolled and persistent infection 3
- Recurrent embolic events 3
- Presence of abscesses, which are associated with a higher morbidity and mortality 2
Timing of Surgery
The optimal timing of surgery remains unclear, but early surgery may be associated with:
- Shorter length of stay and lower hospital costs 5
- Clear blood cultures sooner and earlier defervescence 4
- Complete resolution of valve vegetations 4
Surgical Management
Surgical management is fundamental in the standard of care of selected endocarditis patients and can be a lifesaving procedure in critically ill patients 3. Valve surgery can be performed in patients with native valve or prosthetic valve endocarditis 6, and early surgery is warranted in patients with isolated tricuspid valve endocarditis who are bacteremic and/or systemically infected despite optimal medical therapy 4.