Surgery

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Indications

Heart failure

surgery particularly urgent for patients with aortic valve endocarditis and heart failure
peripoperative mortality higher for patients with heart failure but overall mortality lower in those patients who undergo surgery than in those who receive medical treatment only

Failure to control infection

failure of adequate improvement in fever and other markers of systemic inflammation
at least one week of appropriate antibiotic therapy
no other source of infection

Systemic emboli

embolic episode and residual large and mobile vegetations
opinion divided as to whether surgery is indicated when there are large and mobile vegetations but no embolic event
- embolic risk decreases with duration of antibiotic treatment
  - 15% after one week, 1% after four weeks

Perivalvular infection

abscesses, intracardiac fistulae
more commonly associated with aortic and prosthetic valve infection
early surgery recommended as perioperative risk increases with delay

Valvular obstruction

Unstable prosthesis

haemodynamic deterioration usually occurs quickly
early surgery recommended

Prosthetic valve endocarditis

surgery recommended for Staph. aureus infection associated with intracardiac lesion (eg abscess or dehiscience of prosthesis)
medical treatment alone may be sufficient for late (>12 months) prosthetic valve endocarditis caused by oral streptococci or HACEK organisms if there are no signs of perivalvular infection

Fungi and other difficult to treat organisms

surgery usually needed for:
- fungal endocarditis. Early surgery usually required
- certain Gram negative bacilli (eg Pseudomonas aeruginosa, Achromobacter xylosoxitans)
- Brucella
- highly resistant enterococci

Preoperative investigations

CT brain to exclude asymptomatic cerebral haemorrhage
- if haemorrhage detected, angiography should be performed to look for mycotic aneurysms
- ruptured mycotic aneurysms should be clipped prior to surgery

Timing

Emergency (same day)	Urgent (within 1-2 days)	Early
Acute aortic regurgitation with early closure of mitral valve Rupture of sinus of Valsalva aneurysm Rupture into pericardium	Valvular obstruction Unstable prosthesis Acute aortic regurgitation or mitral regurgitation with NYHA class III-IV heart failure Septal perforation Annular or aortic abscess, sinus or aortic aneurysm, fistula or new onset conduction block Major embolism and mobile vegetation >10 mm and appropriate antibiotic therapy <7-10 days Mobile vegetation >15 mm and appropriate antibiotic therapy <7-10 days No effective antimicrobial therapy available	Staphylococcal prosthetic endocarditis Early prosthetic valve endocarditis (<3 months after surgery) Progressive paraprosthetic leak Valve dysfunction and persistent inflammatory response or bacteraemia after 7-10 days of appropriate antibiotics in absence of other cause for infection Fungal infection Infection with difficult to treat organisms Increase in size of vegetations despite antibiotic treatment for >7 days

Further reading

Delahaye F et al. Indications and optimal timing for surgery in infective endocarditis. Heart, 2004; 90:618-20

©Charles Gomersall, May, 2009 unless otherwise stated. The author, editor and The Chinese University of Hong Kong take no responsibility for any adverse event resulting from the use of this webpage.
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