What are the indications for valve replacement in infective endocarditis?

Indications for Valve Replacement in Infective Endocarditis

Valve replacement surgery is indicated in infective endocarditis patients with heart failure, uncontrolled infection, or high risk of embolism, with timing (emergency, urgent, or elective) based on clinical severity. 1

Native Valve Endocarditis - Class I Indications (Strongest Recommendations)

• Heart Failure: Surgery is indicated in patients with valve stenosis or regurgitation resulting in heart failure or hemodynamic compromise 1
• Hemodynamic Evidence: Surgery is indicated with aortic or mitral regurgitation with elevated LV end-diastolic or left atrial pressures (e.g., premature closure of mitral valve with aortic regurgitation, rapid deceleration of MR signal by continuous-wave Doppler) 1
• Resistant Organisms: Surgery is indicated for endocarditis caused by fungi or other highly resistant organisms 1
• Structural Complications: Surgery is indicated when endocarditis is complicated by heart block, annular or aortic abscess, or destructive penetrating lesions (e.g., sinus of Valsalva fistula, mitral leaflet perforation) 1

Native Valve Endocarditis - Class IIa Indications (Reasonable)

• Recurrent Emboli: Surgery is reasonable in patients with recurrent emboli and persistent vegetations despite appropriate antibiotic therapy 1

Native Valve Endocarditis - Class IIb Indications (May Be Considered)

• Large Vegetations: Surgery may be considered in patients with mobile vegetations >10 mm with or without emboli 1

Prosthetic Valve Endocarditis - Class I Indications

• Surgical Consultation: Consultation with a cardiac surgeon is indicated for all patients with prosthetic valve endocarditis 1
• Heart Failure: Surgery is indicated for prosthetic valve endocarditis patients with heart failure 1
• Valve Dehiscence: Surgery is indicated when there is evidence of prosthetic valve dehiscence seen on imaging 1
• Worsening Function: Surgery is indicated with evidence of increasing obstruction or worsening regurgitation 1
• Complications: Surgery is indicated when there are complications such as abscess formation 1

Prosthetic Valve Endocarditis - Class IIa Indications

• Persistent Infection: Surgery is reasonable for patients with evidence of persistent bacteremia or recurrent emboli despite appropriate antibiotic treatment 1
• Relapsing Infection: Surgery is reasonable for patients with relapsing infection 1

Timing of Surgery Based on 2015 ESC Guidelines

• Emergency Surgery (within 24 hours): For patients with severe acute regurgitation, obstruction or fistula causing refractory pulmonary edema or cardiogenic shock 1
• Urgent Surgery (within days): For patients with:
  • Heart failure with severe regurgitation or obstruction 1
  • Uncontrolled local infection (abscess, false aneurysm, fistula, enlarging vegetation) 1
  • Persistent vegetations >10mm after embolic episode despite antibiotics 1
• Elective Surgery (after 1-2 weeks of antibiotics): For less urgent cases 1

Special Considerations

• S. aureus infections: Both prosthetic valve endocarditis and native valve endocarditis caused by S. aureus are almost always surgical diseases 1, 2
• Valve repair vs. replacement: When possible, valve repair (especially for mitral valve) is preferable to replacement to reduce risk of prosthetic material infection 1
• Anticoagulation management: Patients on warfarin should have it discontinued and replaced with heparin when endocarditis is diagnosed, in case urgent surgery is needed 1
• Vegetation size: Patients with vegetation diameter >10mm have significantly higher incidence of embolization, particularly with mitral valve involvement 1

Common Pitfalls

• Delaying surgery: Procrastination in patients with progressive or severe heart failure due to endocarditis leads to worse outcomes 3
• Overlooking subtle hemodynamic compromise: Even without overt heart failure, signs of hemodynamic compromise warrant surgical intervention 1
• Focusing only on infection control: While appropriate antibiotics are essential, mechanical problems (regurgitation, obstruction) often require surgical correction 1
• Ignoring high-risk pathogens: Certain organisms (S. aureus, fungi) have poor outcomes with medical therapy alone and typically require surgical intervention 2

Outcomes

• Operative mortality for valve replacement in active endocarditis ranges from 7-10% in most series, but outcomes are generally favorable with appropriate patient selection 4, 2
• Five-year survival rates after valve replacement for endocarditis range from 53-68% 4, 2
• Early surgery in appropriate candidates can lead to excellent clinical improvement in up to 95% of survivors 4