From the Guidelines
Surgical intervention for endocarditis is indicated in patients with heart failure, uncontrolled infection, or evidence of embolization, as recommended by the 2015 ESC guidelines 1.
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, or persisting positive blood cultures despite appropriate antibiotic therapy
- Prevention of embolism, including persistent vegetations >10 mm after one or more embolic episodes, or isolated very large vegetations (>30 mm)
Timing of Surgery
- Emergency surgery (within 24 hours) is recommended for severe heart failure or cardiogenic shock
- Urgent surgery (within days) is recommended for uncontrolled infection or prevention of embolic events
- Elective surgery is recommended for stable patients requiring valve replacement
Additional Considerations
- Prosthetic valve endocarditis, particularly early cases (within 12 months of valve placement), often requires surgical management, as does endocarditis caused by Staphylococcus aureus involving prosthetic valves or associated with perivalvular complications 1
- Early surgical consultation is essential in all cases of endocarditis to determine optimal timing and approach, as delayed intervention in appropriate candidates can significantly increase mortality risk
- The 2008 ACC/AHA guidelines also recommend consultation with a cardiac surgeon for patients with infective endocarditis of a prosthetic valve, and surgery for patients with prosthetic valve endocarditis who present with heart failure, dehiscence, or complications such as abscess formation 1
From the Research
Surgical Indications for Endocarditis
The surgical indications for endocarditis include:
- Heart failure, most commonly from acute valvular insufficiency 2
- Uncontrolled and persistent infection 2, 3
- Recurrent embolic events 2, 3
- Large mobile vegetations 4, 3
- Prosthetic valve endocarditis 4
- Peripheral embolism 4
Timing of Surgery
The optimal timing of surgery remains unclear, but early surgery can avoid death and severe complications 3. The decision for surgical timing should be based on individual risk-benefit analysis, and early surgery is strongly indicated if its benefits exceed operative risks 3. Urgent surgery is indicated in patients who have moderate to severe heart failure, uncontrolled infection, and large vegetations associated with severe valvular disease 3.
Valve Repair and Replacement
Valve repair should be considered for patients with mitral regurgitation due to active infective endocarditis, especially when there is superficial infection without valve destruction 4. However, large defects of the anterior leaflet, due to transmural infection or lesions that encompass greater than one-third of the entire posterior leaflet with annular abscess, are not amenable to repair 4. Valve replacement is often necessary in cases of prosthetic valve endocarditis or when the valve is severely damaged 4, 2.
Complications and Outcomes
The size of vegetations can affect the complication rate, with larger vegetations associated with a higher risk of embolism and mortality 5. Monitoring vegetation size by means of transesophageal echocardiography may be useful for estimating the efficacy of antibiotic treatment, especially in culture-negative patients 5. The choice of antibiotic treatment can also impact vegetation size and complication rate, with some antibiotics associated with a reduction in vegetation size and others with an increased risk of embolism and mortality 5.