From the Guidelines
Surgical intervention for endocarditis is indicated in several specific clinical scenarios, including heart failure, uncontrolled infection, and prevention of embolism, as outlined in the 2015 ESC guidelines 1. The indications for surgery can be broken down into several key areas:
- Heart failure: Surgery is recommended for patients with heart failure due to valve dysfunction, particularly with aortic or mitral regurgitation causing hemodynamic compromise, as indicated by the presence of severe acute regurgitation, obstruction, or fistula causing refractory pulmonary edema or cardiogenic shock 1.
- Uncontrolled infection: Surgery is indicated for locally uncontrolled infection, such as abscess, false aneurysm, fistula, or enlarging vegetation, as well as for infections caused by fungi or multiresistant organisms 1.
- Prevention of embolism: Surgery is recommended for patients with persistent vegetations >10 mm after one or more embolic episodes despite appropriate antibiotic therapy, as well as for those with large vegetations (>15 mm) and no other indication for surgery 1. The timing of surgery is crucial, with emergency surgery (within 24 hours) indicated for severe heart failure or cardiogenic shock, while urgent surgery (within days) is appropriate for most other indications. Some key points to consider when deciding on surgical intervention include:
- The presence of perivalvular extension of infection, including abscess formation, fistulas, or heart block, which represents uncontrolled infection requiring surgical intervention 1.
- The presence of prosthetic valve endocarditis, which often requires surgery, particularly with early-onset infection (within 12 months of valve placement) or with valve dysfunction 1.
- The presence of mobile vegetations, especially on the mitral valve, which may necessitate surgery to prevent systemic embolization 1. Overall, the decision for surgical intervention should balance the benefits of removing infected tissue against the risks of perioperative complications, considering the patient's overall condition and comorbidities.
From the Research
Surgical Indications for Endocarditis
The surgical indications for endocarditis include:
- Heart failure, most commonly from acute valvular insufficiency 2, 3, 4, 5
- Uncontrolled and persistent infection 2, 6
- Recurrent embolic events 2, 3, 6
- Severe perivalvular involvement 6
- High embolic risk 6
- Congestive heart failure 6, 4, 5
- Prosthetic valve endocarditis with cerebral complications 6
- Severe aortic leaflet destruction 6
- Perivalvular extension or uncontrolled infection 6
Timing of Surgery
The optimal time for surgery is before the onset of severe end-stage heart failure or spread of the infection to extravalvular tissue 3. Emergency or urgent surgery should seldom be delayed 4, 5.
Valve Surgery
Valve repair should be considered as an alternative to valve replacement whenever feasible, especially in younger patients 4, 5. Successful management of perivalvular abscesses and prosthetic valve infections requires radical removal of infected tissue followed by reconstructive procedures performed by experienced surgeons 4, 5.