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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, April, 2012 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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